Provider Demographics
NPI:1790819027
Name:DOMEK, ROXANNE R (LPC)
Entity type:Individual
Prefix:
First Name:ROXANNE
Middle Name:R
Last Name:DOMEK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1830 S ALMA SCHOOL RD STE 104
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-3086
Mailing Address - Country:US
Mailing Address - Phone:480-823-0360
Mailing Address - Fax:208-480-9741
Practice Address - Street 1:1830 S ALMA SCHOOL RD STE 104
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-3086
Practice Address - Country:US
Practice Address - Phone:480-823-0360
Practice Address - Fax:208-480-9741
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2025-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-14495101YP2500X
AZLPC101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD4993585OtherBLUE CROSS/BLUE SHIELD