Healthcare Provider Details

I. General information

NPI: 1194448555
Provider Name (Legal Business Name): MADISEN BROOKE KESECKER LPC-R
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2022
Last Update Date: 09/21/2022
Certification Date: 09/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8200 ROLLING RD
SPRINGFIELD VA
22153-3110
US

IV. Provider business mailing address

4905 DICKENS RD STE 106
RICHMOND VA
23230-1953
US

V. Phone/Fax

Practice location:
  • Phone: 703-440-2180
  • Fax:
Mailing address:
  • Phone: 571-550-0767
  • Fax: 804-269-5003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0704015161
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: