Healthcare Provider Details

I. General information

NPI: 1821204959
Provider Name (Legal Business Name): KEMBERLY LILES RAINNEY L.P.C., L.S.A.T.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KEMBERLY ANTOINETTE LILES L.P.C., L.S.A.T.P.

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 09/02/2022
Certification Date: 06/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6013 MANOR HOUSE TRL
MOSELEY VA
23120-2248
US

IV. Provider business mailing address

6013 MANOR HOUSE TRL
MOSELEY VA
23120-2248
US

V. Phone/Fax

Practice location:
  • Phone: 804-248-6964
  • Fax: 866-210-2370
Mailing address:
  • Phone: 804-248-6964
  • Fax: 866-210-2370

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0718000086
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701002907
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: