Provider Demographics
NPI:1578347746
Name:MOWREY, DOMYNIK MATTHEW
Entity Type:Individual
Prefix:MR
First Name:DOMYNIK
Middle Name:MATTHEW
Last Name:MOWREY
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 1:157 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034-1416
Mailing Address - Country:US
Mailing Address - Phone:618-328-8044
Mailing Address - Fax:
Practice Address - Street 1:400 SAINT LOUIS ST STE 1
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-1979
Practice Address - Country:US
Practice Address - Phone:618-226-4397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILRBT-23-286519106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician