Provider Demographics
NPI:1639914781
Name:DOMANICO, MEREDITH (LPC)
Entity type:Individual
Prefix:MRS
First Name:MEREDITH
Middle Name:
Last Name:DOMANICO
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:776 WOODBERRY LN
Mailing Address - Street 2:
Mailing Address - City:BELVIDERE
Mailing Address - State:IL
Mailing Address - Zip Code:61008-7950
Mailing Address - Country:US
Mailing Address - Phone:224-343-4947
Mailing Address - Fax:
Practice Address - Street 1:6653 WEAVER RD STE 112
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-8068
Practice Address - Country:US
Practice Address - Phone:815-201-2687
Practice Address - Fax:844-961-3413
Is Sole Proprietor?:No
Enumeration Date:2024-06-29
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.019456101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional