Provider Demographics
NPI:1134908171
Name:DOMSTEN, KATHLEEN BROWN (LSW)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:BROWN
Last Name:DOMSTEN
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1655 N ARLINGTON HEIGHTS RD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60004-3982
Mailing Address - Country:US
Mailing Address - Phone:224-732-1125
Mailing Address - Fax:
Practice Address - Street 1:1655 N ARLINGTON HEIGHTS RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60004-3982
Practice Address - Country:US
Practice Address - Phone:224-732-1125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-28
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.1113621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical