Healthcare Provider Details

I. General information

NPI: 1780500694
Provider Name (Legal Business Name): DOMINIC LEROSE APSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2026
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3101 LATHAM DR
MADISON WI
53713-4613
US

IV. Provider business mailing address

2 W GORHAM ST APT G1
MADISON WI
53703-2087
US

V. Phone/Fax

Practice location:
  • Phone: 608-286-1132
  • Fax:
Mailing address:
  • Phone: 847-830-2144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number136132121
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: