Provider Demographics
NPI:1194310227
Name:RICE, LISETTE DOMINIQUE
Entity type:Individual
Prefix:
First Name:LISETTE
Middle Name:DOMINIQUE
Last Name:RICE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LISETTE
Other - Middle Name:DOMINIQUE
Other - Last Name:BALLAH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:629 PHOENIX DR STE 150
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-7341
Mailing Address - Country:US
Mailing Address - Phone:757-837-0761
Mailing Address - Fax:
Practice Address - Street 1:629 PHOENIX DR STE 150
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-7341
Practice Address - Country:US
Practice Address - Phone:757-837-0761
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-01
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARBT-20-131643106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician