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General NPI Number Information
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NPI Number | 1790999191
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Entity Type | Individual
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Provider Name | MATTHEW DAVID DOMICO MSW, LCSW
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Gender | Male
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Dates
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Enumeration Date | 05/09/2007
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Last Update Date | 08/31/2025
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Provider Practice Location Address
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Address Line | 712 E WAR MEMORIAL DR
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City | PEORIA
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State | IL
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Zip | 61616-7548
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Country | US
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Telephone | 815-701-6317
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Fax |
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Provider Business Mailing Address
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Address Line | 5901 N PROSPECT RD STE 105
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City | PEORIA
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State | IL
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Zip | 61614-4358
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Country | US
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Telephone | 815-701-6317
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 149013431
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License Number State | IL
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