Provider Demographics
NPI:1194485722
Name:DORO, DOMENICA
Entity type:Individual
Prefix:
First Name:DOMENICA
Middle Name:
Last Name:DORO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2821 FORESTVIEW CT
Mailing Address - Street 2:
Mailing Address - City:CARPENTERSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60110-3378
Mailing Address - Country:US
Mailing Address - Phone:920-366-2934
Mailing Address - Fax:
Practice Address - Street 1:475 W TERRA COTTA AVE STE E
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-3407
Practice Address - Country:US
Practice Address - Phone:815-707-4806
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-22
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.016997101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional