MEDICARE: MRS. ROXANNE B DOMINIS 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	149011984	IL

General Provider Information

NPI Number	:	1497962641
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ROXANNE B DOMINIS LCSW

Provider Business Mailing Address
First Line	:	PO BOX 4439
Second Line	:
City	:	OAK PARK
State	:	IL
Zip	:	60304-0611
Country	:	US
Telephone Number	:	312-375-7428
Fax Number	:	708-456-5505

Provider Business Practice Location Address
First Line	:	2502 N CLARK ST STE 218
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-1850
Country	:	US
Telephone Number	:	312-375-7428
Fax Number	:

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

Provider Enumeration Date	:	05/17/2007
Last Update Date	:	01/16/2019

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