Provider Demographics
NPI:1487495305
Name:DOMIN, MADISON RAE (MSSW,LMSW)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:RAE
Last Name:DOMIN
Suffix:
Gender:F
Credentials:MSSW,LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1114 CAMINO LA COSTA APT 1037
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78752-3949
Mailing Address - Country:US
Mailing Address - Phone:512-924-3306
Mailing Address - Fax:
Practice Address - Street 1:1114 CAMINO LA COSTA APT 1037
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78752-3949
Practice Address - Country:US
Practice Address - Phone:512-924-3306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-04
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX108702104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker