Provider Demographics
NPI:1962604215
Name:DOMINICK, STEPHEN WARD (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:WARD
Last Name:DOMINICK
Suffix:
Gender:M
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:STEVE
Other - Middle Name:
Other - Last Name:DOMINICK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1735 SHERIDAN AVE
Mailing Address - Street 2:SUITE 230
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-3855
Mailing Address - Country:US
Mailing Address - Phone:307-587-8439
Mailing Address - Fax:307-587-8439
Practice Address - Street 1:1735 SHERIDAN AVE
Practice Address - Street 2:SUITE 230
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-3855
Practice Address - Country:US
Practice Address - Phone:307-587-8439
Practice Address - Fax:307-587-8439
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLCSW-1871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYLCSW-187OtherLIC. CLINICAL SOCIAL WORK