Healthcare Provider Details

I. General information

NPI: 1720910920
Provider Name (Legal Business Name): NICKY OWUSU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

384 GREENSTEAD DR
STAFFORD VA
22554-6595
US

IV. Provider business mailing address

384 GREENSTEAD DR
STAFFORD VA
22554-6595
US

V. Phone/Fax

Practice location:
  • Phone: 866-968-6342
  • Fax: 855-615-2876
Mailing address:
  • Phone: 866-968-6342
  • Fax: 855-615-2876

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0704017343
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: