Healthcare Provider Details

I. General information

NPI: 1730892779
Provider Name (Legal Business Name): AMANDA GRACE KEPHART
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2023
Last Update Date: 01/12/2026
Certification Date: 01/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11260 ROGER BACON DR STE 103
RESTON VA
20190-5203
US

IV. Provider business mailing address

PO BOX 748465
ATLANTA GA
30374-8465
US

V. Phone/Fax

Practice location:
  • Phone: 855-284-7483
  • Fax: 617-807-0958
Mailing address:
  • Phone: 855-284-7483
  • Fax: 617-807-0958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701012428
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLH61688079
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: