Healthcare Provider Details

I. General information

NPI: 1255151056
Provider Name (Legal Business Name): BRIANNA ROSE DOMAGALSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2024
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 S HURON PKWY STE 2B
ANN ARBOR MI
48104-5133
US

IV. Provider business mailing address

30850 BROWN ST
GARDEN CITY MI
48135-1401
US

V. Phone/Fax

Practice location:
  • Phone: 734-725-8802
  • Fax:
Mailing address:
  • Phone: 734-308-2904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6451025365APP26
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: