Provider Demographics
NPI:1649445669
Name:DOMECQ, MARCIA (LCSW)
Entity type:Individual
Prefix:
First Name:MARCIA
Middle Name:
Last Name:DOMECQ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 TOWER AVE
Mailing Address - Street 2:ESSENTIA HEALTH ST, MARY'S-SUPERIOR CLINIC
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-4491
Mailing Address - Country:US
Mailing Address - Phone:715-817-7100
Mailing Address - Fax:
Practice Address - Street 1:3500 TOWER AVE
Practice Address - Street 2:ESSENTIA HEALTH ST, MARY'S-SUPERIOR CLINIC
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-4491
Practice Address - Country:US
Practice Address - Phone:715-817-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-30
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3965-123101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health