Provider Demographics
NPI:1790819027
Name:DOMEK, ROXANNE R (LPC)
Entity Type:Individual
Prefix:
First Name:ROXANNE
Middle Name:R
Last Name:DOMEK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2288 E 39TH AVE
Mailing Address - Street 2:
Mailing Address - City:APACHE JUNCTION
Mailing Address - State:AZ
Mailing Address - Zip Code:85119-3647
Mailing Address - Country:US
Mailing Address - Phone:605-440-2059
Mailing Address - Fax:
Practice Address - Street 1:1425 W ELLIOT RD
Practice Address - Street 2:SUITE 201
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85233-5129
Practice Address - Country:US
Practice Address - Phone:605-440-2059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2014-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDLPC949101YM0800X
AZLPC101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD4993585OtherBLUE CROSS/BLUE SHIELD