Provider Demographics
NPI:1982356077
Name:ROXANNE R DOMEK, PLLC
Entity type:Organization
Organization Name:ROXANNE R DOMEK, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROXANNE
Authorized Official - Middle Name:R
Authorized Official - Last Name:DOMEK
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:480-823-0360
Mailing Address - Street 1:3707 E SOUTHERN AVE STE 1066
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-6206
Mailing Address - Country:US
Mailing Address - Phone:480-823-0360
Mailing Address - Fax:
Practice Address - Street 1:3707 E SOUTHERN AVE STE 1066
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-6206
Practice Address - Country:US
Practice Address - Phone:480-823-0360
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-20
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1790819027OtherTYPE I NPI