Healthcare Provider Details

I. General information

NPI: 1295220465
Provider Name (Legal Business Name): BERNNELL KINDZRED JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2018
Last Update Date: 12/29/2021
Certification Date: 12/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2215 LANGHORNE RD
LYNCHBURG VA
24501-1121
US

IV. Provider business mailing address

2215 LANGHORNE RD
LYNCHBURG VA
24501-1121
US

V. Phone/Fax

Practice location:
  • Phone: 434-948-4831
  • Fax:
Mailing address:
  • Phone: 434-948-4831
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0701007735
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701007735
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: