MEDICARE: MR. CHARLES KENT DOMINEY LPC

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	101YP2500X	Professional Counselor	2025	TX

General Provider Information

NPI Number	:	1295833549
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CHARLES KENT DOMINEY LPC

Provider Business Mailing Address
First Line	:	2901 BARTON SKWY
Second Line	:	#2408
City	:	AUSTIN
State	:	TX
Zip	:	78746-6911
Country	:	US
Telephone Number	:	512-328-3710
Fax Number	:	512-328-3710

Provider Business Practice Location Address
First Line	:	2901 BARTON SKWY
Second Line	:	#2408
City	:	AUSTIN
State	:	TX
Zip	:	78746-6911
Country	:	US
Telephone Number	:	512-328-3710
Fax Number	:	512-328-3710

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

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	07/08/2007

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