Provider Demographics
NPI:1255367215
Name:DOMERESE, LINDA M (DMIN, LPCC)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:M
Last Name:DOMERESE
Suffix:
Gender:F
Credentials:DMIN, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2720 FREDERICA ST
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42301-5442
Mailing Address - Country:US
Mailing Address - Phone:270-685-0110
Mailing Address - Fax:
Practice Address - Street 1:2720 FREDERICA ST
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301-5442
Practice Address - Country:US
Practice Address - Phone:270-685-0110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0488101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional