Healthcare Provider Details

I. General information

NPI: 1861442345
Provider Name (Legal Business Name): MICHAEL J DI DOMENICO PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 07/25/2022
Certification Date: 07/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 SKOKIE BLVD STE 600
NORTHBROOK IL
60062-2841
US

IV. Provider business mailing address

PO BOX 472
NORTHBROOK IL
60065-0472
US

V. Phone/Fax

Practice location:
  • Phone: 630-632-0746
  • Fax: 847-272-8221
Mailing address:
  • Phone: 847-504-4060
  • Fax: 847-919-8399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number071005762
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071055762
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071005762
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: