Provider Demographics
NPI:1396230918
Name:MACKSOUD, DOMINICK
Entity Type:Individual
Prefix:
First Name:DOMINICK
Middle Name:
Last Name:MACKSOUD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28990 WILLOW CREEK ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48331-2677
Mailing Address - Country:US
Mailing Address - Phone:248-838-8182
Mailing Address - Fax:
Practice Address - Street 1:7650 SE 27TH ST
Practice Address - Street 2:
Practice Address - City:MERCER ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98040-3060
Practice Address - Country:US
Practice Address - Phone:206-230-8320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-26
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MI5501020247225100000X
WA61217784225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician