Provider Demographics
NPI:1750455226
Name:DOMBROWSKI, RICHARD (PHD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
Last Name:DOMBROWSKI
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:836 CENTENNIAL WAY
Mailing Address - Street 2:SUITE 160
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48917-8238
Mailing Address - Country:US
Mailing Address - Phone:517-703-0110
Mailing Address - Fax:517-703-0113
Practice Address - Street 1:836 CENTENNIAL WAY
Practice Address - Street 2:SUITE 160
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917-8238
Practice Address - Country:US
Practice Address - Phone:517-703-0110
Practice Address - Fax:517-703-0113
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301006528103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
5247231OtherAETNA
61-45416OtherPHP OF MID MI
MI680B345140OtherBLUE CROSS & BLUE SHIELD
5247231OtherAETNA
0C34653Medicare ID - Type Unspecified