Provider Demographics
NPI:1285873224
Name:DOMINICK, NICOLE (MA LLP)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:DOMINICK
Suffix:
Gender:F
Credentials:MA LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42669 GARFIELD RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-5036
Mailing Address - Country:US
Mailing Address - Phone:586-412-5321
Mailing Address - Fax:
Practice Address - Street 1:29750 HARPER AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48082-2607
Practice Address - Country:US
Practice Address - Phone:586-777-3200
Practice Address - Fax:586-777-7855
Is Sole Proprietor?:No
Enumeration Date:2009-02-16
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301011786103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI750910681OtherBLUE CROSS