Healthcare Provider Details

I. General information

NPI: 1083536650
Provider Name (Legal Business Name): KEISHA MAINOR-RICHARDSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2026
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4229 LAFAYETTE CENTER DR STE 1675
CHANTILLY VA
20151-1270
US

IV. Provider business mailing address

906 NE 13TH PL
CAPE CORAL FL
33909-1510
US

V. Phone/Fax

Practice location:
  • Phone: 855-326-4673
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: