Provider Demographics
NPI:1497526339
Name:DOMAN, MAXWEL (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MAXWEL
Middle Name:
Last Name:DOMAN
Suffix:
Gender:M
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2130 W CHICAGO AVE APT 3F
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-4217
Mailing Address - Country:US
Mailing Address - Phone:708-369-7169
Mailing Address - Fax:
Practice Address - Street 1:135 N HARVEY AVE
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-2622
Practice Address - Country:US
Practice Address - Phone:708-369-7169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-10
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146014254235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist