MEDICARE: ROXANNE R DOMEK 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	LPC-14495	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4993585	OTHER	SD	BLUE CROSS/BLUE SHIELD

General Provider Information

NPI Number	:	1790819027
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROXANNE R DOMEK LPC

Provider Business Mailing Address
First Line	:	1830 S ALMA SCHOOL RD STE 104
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85210-3086
Country	:	US
Telephone Number	:	480-823-0360
Fax Number	:	208-480-9741

Provider Business Practice Location Address
First Line	:	1830 S ALMA SCHOOL RD STE 104
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85210-3086
Country	:	US
Telephone Number	:	480-823-0360
Fax Number	:	208-480-9741

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

Provider Enumeration Date	:	03/16/2007
Last Update Date	:	09/26/2025

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