Provider Demographics
NPI:1861442345
Name:DI DOMENICO, MICHAEL J (PSYD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:DI DOMENICO
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 472
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60065-0472
Mailing Address - Country:US
Mailing Address - Phone:847-504-4060
Mailing Address - Fax:847-919-8399
Practice Address - Street 1:707 SKOKIE BLVD STE 600
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-2841
Practice Address - Country:US
Practice Address - Phone:630-632-0746
Practice Address - Fax:847-272-8221
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071055762103TC0700X
IL071005762103TC0700X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1623280OtherBLUE CROSS BLUE SHIELD
P08393Medicare UPIN
IL1623280OtherBLUE CROSS BLUE SHIELD