Basic Information
| Provider Information | |||||||||
| NPI: | 1235266743 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOMINICK | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | LPCC-S, LICDC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 659 BOULEVARD ST | ||||||||
| Address2: | |||||||||
| City: | DOVER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446222026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303433311 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 205 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | DOVER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446222058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303437950 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2007 | ||||||||
| LastUpdateDate: | 05/20/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 111001 | OH | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | E.0600629 SUPV | OH | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.