Healthcare Provider Details

I. General information

NPI: 1104757681
Provider Name (Legal Business Name): MENDED WINGS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2026
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8401 MAYLAND DR # 10737
RICHMOND VA
23294-4648
US

IV. Provider business mailing address

8401 MAYLAND DR # 10737
RICHMOND VA
23294-4648
US

V. Phone/Fax

Practice location:
  • Phone: 703-633-0002
  • Fax:
Mailing address:
  • Phone: 703-633-0002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: KEISHA DENNIS
Title or Position: CEO
Credential: LCSW
Phone: 703-633-0002