Provider Demographics
NPI:1861440588
Name:DOMROE, REBECCA LENORE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:LENORE
Last Name:DOMROE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4576 WATERHOUSE RD
Mailing Address - Street 2:
Mailing Address - City:CLAY
Mailing Address - State:NY
Mailing Address - Zip Code:13041-9613
Mailing Address - Country:US
Mailing Address - Phone:315-652-6338
Mailing Address - Fax:315-652-6338
Practice Address - Street 1:4576 WATERHOUSE RD
Practice Address - Street 2:
Practice Address - City:CLAY
Practice Address - State:NY
Practice Address - Zip Code:13041-9613
Practice Address - Country:US
Practice Address - Phone:315-652-6338
Practice Address - Fax:315-652-6338
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR028514-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYIA0869Medicare ID - Type Unspecified