Healthcare Provider Details

I. General information

NPI: 1205267838
Provider Name (Legal Business Name): DOMINICK CHARLES ALLEN LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: DOMINICK CHARLES ALLEN MAXEY

II. Dates (important events)

Enumeration Date: 12/08/2013
Last Update Date: 04/02/2026
Certification Date: 04/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22232 17TH AVE SE STE 307
BOTHELL WA
98021-7425
US

IV. Provider business mailing address

1469 N 1200 W
OREM UT
84057-2449
US

V. Phone/Fax

Practice location:
  • Phone: 801-655-5450
  • Fax: 385-225-9327
Mailing address:
  • Phone: 801-655-5450
  • Fax: 385-225-9327

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:
Title or Position:
Credential:
Phone: