Provider Demographics
NPI:1104055953
Name:DOMENICO, COURTNEY K (PSYD)
Entity type:Individual
Prefix:DR
First Name:COURTNEY
Middle Name:K
Last Name:DOMENICO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:COURTNEY
Other - Middle Name:D
Other - Last Name:BURTSCHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSY,D
Mailing Address - Street 1:1300 W BELMONT AVE
Mailing Address - Street 2:SUITE 302
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-3200
Mailing Address - Country:US
Mailing Address - Phone:773-883-5398
Mailing Address - Fax:
Practice Address - Street 1:1300 W BELMONT AVE
Practice Address - Street 2:SUITE 302
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-3200
Practice Address - Country:US
Practice Address - Phone:773-883-5398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-14
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071007703103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical