Provider Demographics
NPI:1598381659
Name:DOMINOWSKI, GRETCHEN (LPC-IT, SAC-IT)
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:
Last Name:DOMINOWSKI
Suffix:
Gender:F
Credentials:LPC-IT, SAC-IT
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 22308
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2308
Mailing Address - Country:US
Mailing Address - Phone:920-436-6800
Mailing Address - Fax:920-432-5966
Practice Address - Street 1:1810 APPLETON RD
Practice Address - Street 2:
Practice Address - City:MENASHA
Practice Address - State:WI
Practice Address - Zip Code:54952-1110
Practice Address - Country:US
Practice Address - Phone:920-739-4226
Practice Address - Fax:920-432-5966
Is Sole Proprietor?:No
Enumeration Date:2020-06-24
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19223101YA0400X
WI4648-226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)