Healthcare Provider Details

I. General information

NPI: 1134739972
Provider Name (Legal Business Name): STEFANIE DOMINIK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2020
Last Update Date: 08/06/2020
Certification Date: 08/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1968 W WINNEMAC AVE UNIT 3
CHICAGO IL
60640-2617
US

IV. Provider business mailing address

1968 W WINNEMAC AVE UNIT 3
CHICAGO IL
60640-2617
US

V. Phone/Fax

Practice location:
  • Phone: 773-893-0265
  • Fax:
Mailing address:
  • Phone: 773-893-0265
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: STEFANIE DOMINIK
Title or Position: OWNER
Credential: LCSW
Phone: 224-612-0230