Provider Demographics
NPI:1013413491
Name:KERSHAW, MARITA
Entity Type:Individual
Prefix:
First Name:MARITA
Middle Name:
Last Name:KERSHAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5331 PRINCE EDWARD HWY
Mailing Address - Street 2:
Mailing Address - City:PROSPECT
Mailing Address - State:VA
Mailing Address - Zip Code:23960-8092
Mailing Address - Country:US
Mailing Address - Phone:914-563-8873
Mailing Address - Fax:
Practice Address - Street 1:1000 JEFFERSON ST STE 1B
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24504-1724
Practice Address - Country:US
Practice Address - Phone:434-771-0495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-04
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
VA09040139831041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty