MEDICARE: E & E RESIDENTIAL SUPPORT PROFESSIONALS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1942800594
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	E & E RESIDENTIAL SUPPORT PROFESSIONALS LLC

Provider Business Mailing Address
First Line	:	14221 LINDENDALE RD
Second Line	:
City	:	WOODBRIDGE
State	:	VA
Zip	:	22193-3448
Country	:	US
Telephone Number	:	571-484-6464
Fax Number	:	703-986-0717

Provider Business Practice Location Address
First Line	:	14221 LINDENDALE RD
Second Line	:
City	:	WOODBRIDGE
State	:	VA
Zip	:	22193-3448
Country	:	US
Telephone Number	:	571-484-6464
Fax Number	:	703-986-0717

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	KENNETH KWEKU BANSAH
Credential	:
Telephone Number	:	571-484-6464

Provider Enumeration Date	:	10/30/2020
Last Update Date	:	02/10/2026

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