MEDICARE: LAURIE J DOMSCH MSW, ACSW, LCSW

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	1041C0700X	Clinical Social Worker	004512	MO

General Provider Information

NPI Number	:	1144201104
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURIE J DOMSCH MSW, ACSW, LCSW

Provider Business Mailing Address
First Line	:	67 BISHOP LN
Second Line	:
City	:	KIMBERLING CITY
State	:	MO
Zip	:	65686-9818
Country	:	US
Telephone Number	:	417-272-0055
Fax Number	:	417-272-0055

Provider Business Practice Location Address
First Line	:	11016 STATE HIGHWAY 76
Second Line	:	CLAYBOUGH PLAZA, STE. 23
City	:	REEDS SPRING
State	:	MO
Zip	:	65737-9775
Country	:	US
Telephone Number	:	417-272-0055
Fax Number	:	417-272-0055

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

Provider Enumeration Date	:	11/08/2005
Last Update Date	:	07/08/2007

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