Provider Demographics
NPI:1104528835
Name:GHOLSON, DOMONIQUE (MS OTR/L)
Entity type:Individual
Prefix:
First Name:DOMONIQUE
Middle Name:
Last Name:GHOLSON
Suffix:
Gender:F
Credentials:MS OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8319 MARWOOD DRIVE
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23235
Mailing Address - Country:US
Mailing Address - Phone:804-687-0308
Mailing Address - Fax:
Practice Address - Street 1:100 ENGLAND ST
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:VA
Practice Address - Zip Code:23005-2013
Practice Address - Country:US
Practice Address - Phone:804-368-8475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-20
Last Update Date:2024-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119009849225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist