Provider Demographics
NPI:1164997490
Name:DOMCZEWSKI, OLIVIA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:OLIVIA
Middle Name:
Last Name:DOMCZEWSKI
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 713260
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-0264
Mailing Address - Country:US
Mailing Address - Phone:630-469-9200
Mailing Address - Fax:
Practice Address - Street 1:2340 S HIGHLAND AVE STE 210
Practice Address - Street 2:
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-7132
Practice Address - Country:US
Practice Address - Phone:815-416-6725
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-13
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071009871103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical