Basic Information
| Provider Information | |||||||||
| NPI: | 1851672398 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAPUTA | ||||||||
| FirstName: | DOMINIC | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3010 GRAND AVE | ||||||||
| Address2: | FIRST FLOOR | ||||||||
| City: | WAUKEGAN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600852321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473778972 | ||||||||
| FaxNumber: | 8473778803 | ||||||||
| Practice Location | |||||||||
| Address1: | 3010 GRAND AVE | ||||||||
| Address2: | FIRST FLOOR | ||||||||
| City: | WAUKEGAN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600852321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473778972 | ||||||||
| FaxNumber: | 8473778803 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2011 | ||||||||
| LastUpdateDate: | 08/29/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 149008473 | IL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.