Healthcare Provider Details

I. General information

NPI: 1174316988
Provider Name (Legal Business Name): LADY CHARMAE CHILDRESS LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2025
Last Update Date: 06/28/2026
Certification Date: 06/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 KEMPSVILLE RD STE 104
CHESAPEAKE VA
23320-3868
US

IV. Provider business mailing address

424 NICHOLAS CT APT L
CHESAPEAKE VA
23320-3984
US

V. Phone/Fax

Practice location:
  • Phone: 757-364-9998
  • Fax:
Mailing address:
  • Phone: 757-364-9998
  • Fax: 757-364-9998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number0019020020
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: