Provider Demographics
NPI:1376625517
Name:KILGORE, DENNIS KEITH (PHD, LCSW)
Entity Type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:KEITH
Last Name:KILGORE
Suffix:
Gender:M
Credentials:PHD, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15230 CYPRESS CREEK LN
Mailing Address - Street 2:
Mailing Address - City:DOSWELL
Mailing Address - State:VA
Mailing Address - Zip Code:23047-2173
Mailing Address - Country:US
Mailing Address - Phone:804-908-5702
Mailing Address - Fax:804-639-0445
Practice Address - Street 1:5918 HARBOUR PARK DR
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-2163
Practice Address - Country:US
Practice Address - Phone:804-639-0400
Practice Address - Fax:804-639-0445
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040019301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA12148129OtherUBH
VA216011OtherCOMPSYCH
VA5586634OtherAETNA
VA288961OtherANTHEM
VA255019000OtherMAGELLAN
VA8941254Medicaid
VA216011OtherCOMPSYCH
VA800002697Medicare ID - Type Unspecified