Provider Demographics
NPI:1023394202
Name:DOMINA, MERYL GREER (LCSW, PHD)
Entity Type:Individual
Prefix:PROF
First Name:MERYL
Middle Name:GREER
Last Name:DOMINA
Suffix:
Gender:F
Credentials:LCSW, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1121 LOREN DR
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-2102
Mailing Address - Country:US
Mailing Address - Phone:815-758-4827
Mailing Address - Fax:
Practice Address - Street 1:14 HEALTH SERVICES DRIVE
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115
Practice Address - Country:US
Practice Address - Phone:815-758-8616
Practice Address - Fax:815-758-7569
Is Sole Proprietor?:No
Enumeration Date:2011-11-01
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150-0034611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical