Provider Demographics
NPI:1144201104
Name:DOMSCH, LAURIE J (MSW, ACSW, LCSW)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:J
Last Name:DOMSCH
Suffix:
Gender:F
Credentials:MSW, ACSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 BISHOP LN
Mailing Address - Street 2:
Mailing Address - City:KIMBERLING CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65686-9818
Mailing Address - Country:US
Mailing Address - Phone:417-272-0055
Mailing Address - Fax:417-272-0055
Practice Address - Street 1:11016 STATE HIGHWAY 76
Practice Address - Street 2:CLAYBOUGH PLAZA, STE. 23
Practice Address - City:REEDS SPRING
Practice Address - State:MO
Practice Address - Zip Code:65737-9775
Practice Address - Country:US
Practice Address - Phone:417-272-0055
Practice Address - Fax:417-272-0055
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0045121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical