Healthcare Provider Details

I. General information

NPI: 1114599958
Provider Name (Legal Business Name): OSO WELLNESS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2021
Last Update Date: 05/06/2025
Certification Date: 05/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3530 N COURTHOUSE RD
PROVIDENCE FORGE VA
23140-3408
US

IV. Provider business mailing address

1731 UPLAND RD
WAXAHACHIE TX
75165-1677
US

V. Phone/Fax

Practice location:
  • Phone: 804-409-7525
  • Fax: 804-315-9380
Mailing address:
  • Phone: 804-409-7525
  • Fax: 804-315-9380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MR. KEITH OSO ENGEL
Title or Position: CEO/FOUNDER MMP
Credential: LCSW
Phone: 804-409-7525