Provider Demographics
NPI:1356494736
Name:GILMORE, KESHA (PHD)
Entity Type:Individual
Prefix:
First Name:KESHA
Middle Name:
Last Name:GILMORE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 W BROAD STREET
Mailing Address - Street 2:SUITE 305
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22046
Mailing Address - Country:US
Mailing Address - Phone:703-533-3302
Mailing Address - Fax:703-237-2083
Practice Address - Street 1:701 W BROAD ST
Practice Address - Street 2:SUITE 305
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22046-3220
Practice Address - Country:US
Practice Address - Phone:703-533-3302
Practice Address - Fax:703-237-2083
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810003765103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical