Healthcare Provider Details

I. General information

NPI: 1629900592
Provider Name (Legal Business Name): KEISHA LORRAINE SUMNER LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2026
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3195 OLD WASHINGTON RD STE 216
WALDORF MD
20602-3201
US

IV. Provider business mailing address

PO BOX 1142
BRYANS ROAD MD
20616-1142
US

V. Phone/Fax

Practice location:
  • Phone: 240-230-2786
  • Fax:
Mailing address:
  • Phone: 240-230-2786
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberM06878
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: