Provider Demographics
NPI:1912180159
Name:DOMINO, MICHELE ROSE (MA, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MICHELE
Middle Name:ROSE
Last Name:DOMINO
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:250 CENTER DR
Mailing Address - Street 2:STE 101-A
Mailing Address - City:VERNON HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60061-1582
Mailing Address - Country:US
Mailing Address - Phone:847-816-7200
Mailing Address - Fax:847-816-7210
Practice Address - Street 1:250 CENTER DR
Practice Address - Street 2:STE 101-A
Practice Address - City:VERNON HILLS
Practice Address - State:IL
Practice Address - Zip Code:60061-1582
Practice Address - Country:US
Practice Address - Phone:847-816-7200
Practice Address - Fax:847-816-7210
Is Sole Proprietor?:No
Enumeration Date:2007-12-11
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.008322235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist