Basic Information
| Provider Information | |||||||||
| NPI: | 1285873224 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOMINICK | ||||||||
| FirstName: | NICOLE | ||||||||
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| Credential: | MA LLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 42669 GARFIELD RD | ||||||||
| Address2: | |||||||||
| City: | CLINTON TWP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480385036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864125321 | ||||||||
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| Practice Location | |||||||||
| Address1: | 29750 HARPER AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT CLAIR SHORES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480822607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867773200 | ||||||||
| FaxNumber: | 5867777855 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2009 | ||||||||
| LastUpdateDate: | 02/11/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 6301011786 | MI | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 750910681 | 01 | MI | BLUE CROSS | OTHER |