Healthcare Provider Details

I. General information

NPI: 1356207294
Provider Name (Legal Business Name): DOMMINIQUE ANDREA KINNIE LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2026
Last Update Date: 01/05/2026
Certification Date: 12/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

313 N MATTIS AVE STE 209
CHAMPAIGN IL
61821-2461
US

IV. Provider business mailing address

200 S VINE ST UNIT 112
URBANA IL
61802-3323
US

V. Phone/Fax

Practice location:
  • Phone: 217-377-0299
  • Fax:
Mailing address:
  • Phone: 217-721-5929
  • Fax: 217-721-5929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number178.021280
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: