=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841696135
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHARI DOMINIANNI LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/13/2014
-----------------------------------------------------
Last Update Date | 09/14/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10850 71ST AVE 2G
-----------------------------------------------------
City | FOREST HILLS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11375-4564
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-531-0988
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9070 KIMBERLY BLVD 50
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33434-2861
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-852-0910
-----------------------------------------------------
Fax | 561-852-0960
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 081266
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------