Dominique Marie Wilson, MA, LCPC, CRC

Primary specialty

Professional CounselorTaxonomy code 101YP2500X

License

180.012945 Issued in IL

Practice address

785 Wall St # 200
O Fallon, IL 62269-1959

Phone

(618) 367-2194

NPI assigned

May 8, 2018

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Addresses

Medicare fee-for-service enrollment

Enrolled in NV

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Mental Health Counselor

Education

Other, 2017

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Serene Path WellnessGroup PAC ID 6709318561, 3 clinicians

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

Credentials

Master of Arts

State licenses

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Serene Path Wellness

  • Psychiatric/Mental Health Nurse Practitioner
  • Las Vegas, NV
  • NPI 1437995362
  Medicare reassignment Care Compare group

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1525737600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1597104000000",
    "number": "1407345192",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1109 HIGH VALLEY LN",
            "city": "BELLEVILLE",
            "state": "IL",
            "postal_code": "622216846",
            "telephone_number": "317-900-6556"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "785 WALL ST # 200",
            "city": "O FALLON",
            "state": "IL",
            "postal_code": "622691959",
            "telephone_number": "618-367-2194"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "3550 W Cheyenne Ave",
            "address_purpose": "LOCATION",
            "city": "North Las Vegas",
            "state": "NV",
            "postal_code": "890328212",
            "country_code": "US",
            "telephone_number": "702-570-5421",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "WILSON",
        "first_name": "DOMINIQUE",
        "middle_name": "MARIE",
        "credential": "MA, LCPC, CRC",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2018-05-08",
        "last_updated": "2020-08-11",
        "certification_date": "2020-08-11",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101Y00000X",
            "taxonomy_group": "",
            "desc": "Counselor",
            "state": "NV",
            "license": "CI0365",
            "primary": false
        },
        {
            "code": "101YM0800X",
            "taxonomy_group": "",
            "desc": "Counselor, Mental Health",
            "state": "NV",
            "license": "CI0365",
            "primary": false
        },
        {
            "code": "101YP2500X",
            "taxonomy_group": "",
            "desc": "Counselor, Professional",
            "state": "IL",
            "license": "180.012945",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Jeffrey Allen Williams, D.C.
• Madison Williams, BT
• Porscha Williams
• Stephanie Williams
• Amanda Lee Wilson, OTR/L
• Tessa Wilson
• Tremiya Renae Winbush
• Roxanne Winebaugh, DMD
• Margaret Winkeler, RN, IBCLC, CEIM
• Laurean Jada Winston, PA-C

• Professional Counselor in O Fallon, IL
• Providers in O Fallon, IL by specialty
• Professional Counselor in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 11, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.