Provider Demographics
NPI:1982228219
Name:DOMESCIK, BRE A (LMHC)
Entity Type:Individual
Prefix:
First Name:BRE
Middle Name:A
Last Name:DOMESCIK
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 S 1ST ST STE 2
Mailing Address - Street 2:
Mailing Address - City:ZIONSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46077-1602
Mailing Address - Country:US
Mailing Address - Phone:317-827-7719
Mailing Address - Fax:
Practice Address - Street 1:260 S 1ST ST STE 2
Practice Address - Street 2:
Practice Address - City:ZIONSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46077-1602
Practice Address - Country:US
Practice Address - Phone:317-827-7719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-02
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39003707A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN39003707AOtherBEHAVIORAL HEALTH BOARD