Provider Demographics
NPI:1407516594
Name:DOMANICK, NICOLE SIERRA RENEE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:SIERRA RENEE
Last Name:DOMANICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICKI
Other - Middle Name:
Other - Last Name:DOMANICK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5522 LONE STAR PKWY STE 101
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78253-6719
Mailing Address - Country:US
Mailing Address - Phone:855-782-7822
Mailing Address - Fax:
Practice Address - Street 1:5522 LONE STAR PKWY STE 101
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78253-6719
Practice Address - Country:US
Practice Address - Phone:855-782-7822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-30
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician