Provider Demographics
NPI:1821337601
Name:DOMINCZAK, DEBRA MARIE (LPC IT)
Entity Type:Individual
Prefix:MRS
First Name:DEBRA
Middle Name:MARIE
Last Name:DOMINCZAK
Suffix:
Gender:F
Credentials:LPC IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N6781 HARRISON RD
Mailing Address - Street 2:
Mailing Address - City:HILBERT
Mailing Address - State:WI
Mailing Address - Zip Code:54129-9262
Mailing Address - Country:US
Mailing Address - Phone:920-989-2370
Mailing Address - Fax:
Practice Address - Street 1:1478 KENWOOD DR STE 1
Practice Address - Street 2:
Practice Address - City:MENASHA
Practice Address - State:WI
Practice Address - Zip Code:54952-1161
Practice Address - Country:US
Practice Address - Phone:920-886-9319
Practice Address - Fax:920-886-9357
Is Sole Proprietor?:No
Enumeration Date:2013-02-13
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1440-226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health