Healthcare Provider Details

I. General information

NPI: 1154146553
Provider Name (Legal Business Name): INTEGRATED INDIVIDUAL AND FAMILY THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2024
Last Update Date: 12/18/2024
Certification Date: 12/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8401 MAYLAND DR # 5035
RICHMOND VA
23294-4648
US

IV. Provider business mailing address

PO BOX 1758
WOODBRIDGE VA
22195-1758
US

V. Phone/Fax

Practice location:
  • Phone: 703-688-2746
  • Fax:
Mailing address:
  • Phone: 703-688-2746
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: KENESHA T HALL
Title or Position: BEHAVIORAL HEALTH THERAPIST
Credential: LCSW
Phone: 626-344-4930