Provider Demographics
NPI:1124862032
Name:CREDLE, KIERRA ESSENCE II
Entity type:Individual
Prefix:
First Name:KIERRA
Middle Name:ESSENCE
Last Name:CREDLE
Suffix:II
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 1:601 ARMSTEAD LOOP APT 3D
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23602-4535
Mailing Address - Country:US
Mailing Address - Phone:347-421-4631
Mailing Address - Fax:
Practice Address - Street 1:156 STRAWBERRY PLAINS RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-3409
Practice Address - Country:US
Practice Address - Phone:757-873-8566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-24
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician