Provider Demographics
NPI:1962397620
Name:DOMASK, MAIAH CLAIRE (MS, LPC-IT)
Entity type:Individual
Prefix:
First Name:MAIAH
Middle Name:CLAIRE
Last Name:DOMASK
Suffix:
Gender:F
Credentials:MS, LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 E MASON ST UNIT 507
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-3573
Mailing Address - Country:US
Mailing Address - Phone:920-210-3975
Mailing Address - Fax:
Practice Address - Street 1:N91W17194 APPLETON AVE STE 204
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-2083
Practice Address - Country:US
Practice Address - Phone:414-209-4007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-11
Last Update Date:2025-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional