Healthcare Provider Details

I. General information

NPI: 1841386059
Provider Name (Legal Business Name): KELLY RAE DOMINICI LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 12/20/2022
Certification Date: 12/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 E FOURTH PLAIN BLVD # V3-SATP
VANCOUVER WA
98661-3753
US

IV. Provider business mailing address

3818 N PIONEER CANYON DR
RIDGEFIELD WA
98642-8288
US

V. Phone/Fax

Practice location:
  • Phone: 503-237-5296
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: