Provider Demographics
NPI:1619587060
Name:KERANEN, DOMINIQUE LARISSA (LLMSW)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:LARISSA
Last Name:KERANEN
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:STANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48888-9702
Mailing Address - Country:US
Mailing Address - Phone:989-831-7672
Mailing Address - Fax:989-831-7578
Practice Address - Street 1:611 N STATE ST
Practice Address - Street 2:
Practice Address - City:STANTON
Practice Address - State:MI
Practice Address - Zip Code:48888-9702
Practice Address - Country:US
Practice Address - Phone:989-831-7672
Practice Address - Fax:989-831-7578
Is Sole Proprietor?:No
Enumeration Date:2020-07-31
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011075651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical