Provider Demographics
NPI:1760666424
Name:DOMINO, MARY ELIZABETH (LCSW-C)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELIZABETH
Last Name:DOMINO
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:MRS
Other - First Name:MARY
Other - Middle Name:ELIZABETH
Other - Last Name:HALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW-C
Mailing Address - Street 1:120 BANJO LN.
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21617
Mailing Address - Country:US
Mailing Address - Phone:410-758-2211
Mailing Address - Fax:410-758-0698
Practice Address - Street 1:120 BANJO LANE
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:MD
Practice Address - Zip Code:21617
Practice Address - Country:US
Practice Address - Phone:410-758-3050
Practice Address - Fax:410-758-0698
Is Sole Proprietor?:No
Enumeration Date:2007-12-18
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD107911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical