Provider Demographics
NPI:1790062321
Name:RICE, DOMONIQUE LA'TOYA (IMFT-S)
Entity Type:Individual
Prefix:DR
First Name:DOMONIQUE
Middle Name:LA'TOYA
Last Name:RICE
Suffix:
Gender:F
Credentials:IMFT-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1491 POLARIS PKWY STE 216
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43240-2041
Mailing Address - Country:US
Mailing Address - Phone:614-568-1258
Mailing Address - Fax:
Practice Address - Street 1:1542 GROVE HILL DRIVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43240
Practice Address - Country:US
Practice Address - Phone:614-568-1258
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-10
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0717001625106H00000X
OHM.1100005106H00000X
OHF.1800041-SUPV106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1790062321Medicaid