Provider Demographics
NPI:1992285647
Name:DOMZALSKI, GRACE
Entity type:Individual
Prefix:DR
First Name:GRACE
Middle Name:
Last Name:DOMZALSKI
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 1:1602 W COLONIAL PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:INVERNESS
Mailing Address - State:IL
Mailing Address - Zip Code:60067-1215
Mailing Address - Country:US
Mailing Address - Phone:847-364-0163
Mailing Address - Fax:
Practice Address - Street 1:1602 W COLONIAL PKWY STE 200
Practice Address - Street 2:
Practice Address - City:INVERNESS
Practice Address - State:IL
Practice Address - Zip Code:60067-1215
Practice Address - Country:US
Practice Address - Phone:847-364-0163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-21
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.010965103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical