Healthcare Provider Details

I. General information

NPI: 1023835360
Provider Name (Legal Business Name): KAITLYN GRACE ROCHELLE LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2024
Last Update Date: 10/22/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 RUDDY DUCK CT
RICHMOND VA
23231-8952
US

IV. Provider business mailing address

5014 MONUMENT AVE
RICHMOND VA
23230-3620
US

V. Phone/Fax

Practice location:
  • Phone: 804-338-4035
  • Fax:
Mailing address:
  • Phone: 804-497-4676
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701010903
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: