Provider Demographics
NPI:1205603008
Name:DOMINISKI, MADELYN (LGPC)
Entity type:Individual
Prefix:
First Name:MADELYN
Middle Name:
Last Name:DOMINISKI
Suffix:
Gender:F
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6655 SANTA BARBARA RD UNIT 8574
Mailing Address - Street 2:
Mailing Address - City:ELKRIDGE
Mailing Address - State:MD
Mailing Address - Zip Code:21075-7523
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6655 SANTA BARBARA RD UNIT 8574
Practice Address - Street 2:
Practice Address - City:ELKRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21075-7523
Practice Address - Country:US
Practice Address - Phone:866-968-6342
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-11
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP14567101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health