Healthcare Provider Details

I. General information

NPI: 1548111222
Provider Name (Legal Business Name): CHRISTINA MINER RESIDENT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2026
Last Update Date: 02/07/2026
Certification Date: 02/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9850 LORI RD
CHESTERFIELD VA
23832-6758
US

IV. Provider business mailing address

1050 TEMPLE AVE PMB# 221
COLONIAL HEIGHTS VA
23834
US

V. Phone/Fax

Practice location:
  • Phone: 804-353-3585
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0704018911
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: