Michael J Di Domenico, PSYD

Primary specialty

Clinical NeuropsychologistTaxonomy code 103G00000X

License

071005762 Issued in IL

Practice address

707 Skokie Blvd Ste 600
Northbrook, IL 60062-2841

Phone

(630) 632-0746

Fax

(847) 272-8221

NPI assigned

May 12, 2006

Sex

Male

Sole proprietor

Yes

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

Specialties & licenses 3

Addresses

Other identifiers 1

Electronic endpoints 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

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.

• Sennogroup, SC

  • Physical Medicine & Rehabilitation Physician
  • Northbrook, IL
  • NPI 1346486735

  Single Specialty

  NPD (past)
• Total Rehab PC

  • Physical Therapist
  • Roselle, IL
  • NPI 1629249917

  Single Specialty

  NPD (past)

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

{
    "created_epoch": "1147392000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1658707200000",
    "number": "1861442345",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 472",
            "city": "NORTHBROOK",
            "state": "IL",
            "postal_code": "600650472",
            "telephone_number": "847-504-4060",
            "fax_number": "847-919-8399"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "707 SKOKIE BLVD STE 600",
            "city": "NORTHBROOK",
            "state": "IL",
            "postal_code": "600622841",
            "telephone_number": "630-632-0746",
            "fax_number": "847-272-8221"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "DI DOMENICO",
        "first_name": "MICHAEL",
        "middle_name": "J",
        "credential": "PSYD",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2006-05-12",
        "last_updated": "2022-07-25",
        "certification_date": "2022-07-14",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Psychologist, Clinical",
            "state": "IL",
            "license": "071055762",
            "primary": false
        },
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "IL",
            "license": "071005762",
            "primary": false
        },
        {
            "code": "103G00000X",
            "taxonomy_group": "",
            "desc": "Clinical Neuropsychologist",
            "state": "IL",
            "license": "071005762",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD",
            "identifier": "1623280",
            "state": "IL"
        }
    ],
    "endpoints": [
        {
            "endpointType": "OTHERS",
            "endpointTypeDescription": "Other URL",
            "endpoint": "n/a",
            "affiliation": "N",
            "endpointDescription": "NA",
            "use": "OTHER",
            "useDescription": "Other",
            "useOtherDescription": "NA",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "NA",
            "address_1": "910 Skokie Blvd Ste 201",
            "city": "Northbrook",
            "state": "IL",
            "country_code": "US",
            "postal_code": "600624033",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Ruvini Devas Gunawardhane, APN-CNP
• Elisabeth Emelie Devik
• Katie Dewitt-Millard, RBT-18-64681
• Margaret Dewitt
• Purvi Dhruva, PHARMD
• Diagnostic and Developmental Center
• Johanna Diamond, PT, DPT
• Diaspora Radiology, SC (Smart Scan Medical Imaging, SC)
• Kristine Dibartolo
• Gloria A Digennaro, D.D.S.

• Clinical Neuropsychologist in Northbrook, IL
• Providers in Northbrook, IL by specialty
• Clinical Neuropsychologist in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 25, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.