Healthcare Provider Details

I. General information

NPI: 1902314271
Provider Name (Legal Business Name): KLG COUNSELING & CONSULTING SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2018
Last Update Date: 01/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 MUSKET LN
HAMPTON VA
23666-5345
US

IV. Provider business mailing address

12 MUSKET LN
HAMPTON VA
23666-5345
US

V. Phone/Fax

Practice location:
  • Phone: 757-344-3848
  • Fax:
Mailing address:
  • Phone: 757-344-3848
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904008950
License Number StateVA

VIII. Authorized Official

Name: KENYUATIA LYNN GASH
Title or Position: CEO/FOUNDER
Credential: LCSW
Phone: 757-344-3848