Provider Demographics
NPI:1740888544
Name:DOMASK, RENE BETH (LPC)
Entity type:Individual
Prefix:
First Name:RENE
Middle Name:BETH
Last Name:DOMASK
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 1:760 QUARTERDECK LN # 2102B
Mailing Address - Street 2:
Mailing Address - City:STURGEON BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54235-3639
Mailing Address - Country:US
Mailing Address - Phone:920-851-6404
Mailing Address - Fax:
Practice Address - Street 1:760 QUARTERDECK LN # 2102B
Practice Address - Street 2:
Practice Address - City:STURGEON BAY
Practice Address - State:WI
Practice Address - Zip Code:54235-3639
Practice Address - Country:US
Practice Address - Phone:920-851-6404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-14
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6882-125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health