Healthcare Provider Details

I. General information

NPI: 1396661799
Provider Name (Legal Business Name): KECIA CAMPBELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2026
Last Update Date: 06/29/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5804 MAPLEDALE PLAZA
DALE CITY VA
22193
US

IV. Provider business mailing address

3607 EAGLE ROCK CT
WOODBRIDGE VA
22192-6403
US

V. Phone/Fax

Practice location:
  • Phone: 571-402-5774
  • Fax:
Mailing address:
  • Phone: 703-342-2068
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number0019011771
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: