Healthcare Provider Details

I. General information

NPI: 1609704014
Provider Name (Legal Business Name): DOMINO COUNSELING SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2026
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2380 CLUB MERIDIAN DR APT B1
OKEMOS MI
48864-4514
US

IV. Provider business mailing address

PO BOX 1454
OKEMOS MI
48805-1454
US

V. Phone/Fax

Practice location:
  • Phone: 702-469-4167
  • Fax:
Mailing address:
  • Phone: 517-258-1506
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: JASON ROY MOTT
Title or Position: OWNER
Credential: LPC
Phone: 702-469-4167