Provider Demographics
NPI:1043673015
Name:MARTIN, DOMINIQUE M (LIMFT)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:M
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LIMFT
Other - Prefix:
Other - First Name:DOMINIQUE
Other - Middle Name:M
Other - Last Name:STARR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:DEPT 781625
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1625
Mailing Address - Country:US
Mailing Address - Phone:614-355-8004
Mailing Address - Fax:614-355-2220
Practice Address - Street 1:399 E MAIN ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-5384
Practice Address - Country:US
Practice Address - Phone:614-355-8550
Practice Address - Fax:614-355-8593
Is Sole Proprietor?:No
Enumeration Date:2016-03-29
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHM.1600007106H00000X
OHF.1800067106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1473276Medicaid