Provider Demographics
NPI:1497962641
Name:DOMINIS, ROXANNE B (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:ROXANNE
Middle Name:B
Last Name:DOMINIS
Suffix:
Gender:F
Credentials:LCSW
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 4439
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60304-0611
Mailing Address - Country:US
Mailing Address - Phone:312-375-7428
Mailing Address - Fax:708-456-5505
Practice Address - Street 1:2502 N CLARK ST STE 218
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-1850
Practice Address - Country:US
Practice Address - Phone:312-375-7428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490119841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical