Provider Demographics
NPI:1356081012
Name:MATTHEWS, KIESHARA A
Entity Type:Individual
Prefix:
First Name:KIESHARA
Middle Name:A
Last Name:MATTHEWS
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:PO BOX 64516
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23467-4516
Mailing Address - Country:US
Mailing Address - Phone:757-724-0351
Mailing Address - Fax:
Practice Address - Street 1:7460 CENTRAL BUSINESS PARK DRIVE
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23513
Practice Address - Country:US
Practice Address - Phone:757-778-9800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-30
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040165171041C0700X
VA0906011428104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker