Healthcare Provider Details

I. General information

NPI: 1770173577
Provider Name (Legal Business Name): KRISTEL M THOMPSON-BUSH LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2021
Last Update Date: 01/25/2021
Certification Date: 01/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 BYRD AVE STE 103
RICHMOND VA
23230-3033
US

IV. Provider business mailing address

1900 BYRD AVE STE 103
RICHMOND VA
23230-3033
US

V. Phone/Fax

Practice location:
  • Phone: 804-592-6311
  • Fax: 844-227-7690
Mailing address:
  • Phone: 804-592-6311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904012597
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: