Healthcare Provider Details

I. General information

NPI: 1811322928
Provider Name (Legal Business Name): KINGDOM COUNSELING SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2013
Last Update Date: 11/16/2021
Certification Date: 11/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 FARLEY BRANCH DRIVE
LYNCHBURG VA
24502-2363
US

IV. Provider business mailing address

121 FARLEY BRANCH DRIVE P.O. BOX 4614
LYNCHBURG VA
24502-0614
US

V. Phone/Fax

Practice location:
  • Phone: 434-515-0503
  • Fax: 434-237-0332
Mailing address:
  • Phone: 434-515-0503
  • Fax: 434-237-0332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number0904007352
License Number StateVA

VIII. Authorized Official

Name: MRS. STEPHANIE SWAIN TUCKER
Title or Position: OWNER/SOLE PRACTITIONER
Credential: LCSW
Phone: 434-515-0503