Provider Demographics
NPI:1295251940
Name:DOMINGUEZ, MARIA MELINA (LCPC)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:MELINA
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1138 N. MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:ALGONQUIN
Mailing Address - State:IL
Mailing Address - Zip Code:60102
Mailing Address - Country:US
Mailing Address - Phone:847-658-4224
Mailing Address - Fax:847-658-4226
Practice Address - Street 1:1138 N. MAIN STREET
Practice Address - Street 2:
Practice Address - City:ALGONQUIN
Practice Address - State:IL
Practice Address - Zip Code:60102
Practice Address - Country:US
Practice Address - Phone:847-658-4224
Practice Address - Fax:847-658-4226
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-15
Last Update Date:2017-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180007120101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional