Provider Demographics
NPI:1518427731
Name:DOMINGUEZ, KATIE MARIE (LCPC, R-DMT, GL-CMA)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:MARIE
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:LCPC, R-DMT, GL-CMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7639 N GREENVIEW AVE APT 3W
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626-1291
Mailing Address - Country:US
Mailing Address - Phone:773-373-9682
Mailing Address - Fax:773-312-4876
Practice Address - Street 1:7639 N GREENVIEW AVE APT 3W
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60626-1291
Practice Address - Country:US
Practice Address - Phone:773-373-9682
Practice Address - Fax:773-312-4876
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-22
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
IL180.013363101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1093474652OtherBCBS PPO INSURANCE OUTPATIENT PROVIDER
IL6839423OtherAETNA PPO OUTPATIENT PROVIDER