Provider Demographics
NPI:1952503443
Name:DOMANSKA-MIVILLE, WIESIA (LCPC)
Entity Type:Individual
Prefix:
First Name:WIESIA
Middle Name:
Last Name:DOMANSKA-MIVILLE
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:WIESLAWA
Other - Middle Name:
Other - Last Name:DOMANSKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED, LCPC ID, LPC TX
Mailing Address - Street 1:1412 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-5038
Mailing Address - Country:US
Mailing Address - Phone:208-957-0957
Mailing Address - Fax:
Practice Address - Street 1:1412 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-5038
Practice Address - Country:US
Practice Address - Phone:208-957-0957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-05
Last Update Date:2013-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX60570101YP2500X
ID5133101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional