MEDICARE: KELLY M DOMINIC LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	F.2200291	OH

General Provider Information

NPI Number	:	1073007985
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY M DOMINIC LMFT

Provider Business Mailing Address
First Line	:	10955 CLEARPORT RD SW
Second Line	:
City	:	AMANDA
State	:	OH
Zip	:	43102-9612
Country	:	US
Telephone Number	:	330-730-9511
Fax Number	:	614-437-2580

Provider Business Practice Location Address
First Line	:	408 N COLUMBUS ST
Second Line	:
City	:	LANCASTER
State	:	OH
Zip	:	43130-3033
Country	:	US
Telephone Number	:	740-206-8659
Fax Number	:	614-437-2580

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/15/2018
Last Update Date	:	04/06/2026

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Directions to “ KELLY M DOMINIC LMFT” Practice Location

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