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Individual
KATIE MARIE DOMINGUEZ
Active
Individual
KATIE MARIE DOMINGUEZ
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
LCPC, R-DMT, GL-CMA
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
Primary
180.013363
IL
101YP2500X
Professional Counselor
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1093474652
BCBS PPO INSURANCE OUTPATIENT PROVIDER
IL
01
—
6839423
AETNA PPO OUTPATIENT PROVIDER
IL
Enumeration date
03/22/2019
Last updated
09/09/2022
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