Basic Information
| Provider Information | |||||||||
| NPI: | 1033342225 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOMB | ||||||||
| FirstName: | SHERRIE | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | B.A.,M.S. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SCHNEIDER | ||||||||
| OtherFirstName: | SHERRIE | ||||||||
| OtherMiddleName: | JOY | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6700 WASHINGTON AVE S | ||||||||
| Address2: | |||||||||
| City: | EDEN PRAIRIE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553443405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003288602 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 123 N CONGRESS AVE STE A | ||||||||
| Address2: | |||||||||
| City: | BOYNTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334265132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5612854020 | ||||||||
| FaxNumber: | 5036595968 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/03/2009 | ||||||||
| LastUpdateDate: | 04/11/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | Y | Speech, Language and Hearing Service Providers | Audiologist | 237600000X | N | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter | 237700000X | N | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |
ID Information
| ID | Type | State | Issuer | Description | HB811Z | 01 | MEDICARE | OTHER | HB811Y | 01 | MEDICARE | OTHER |