Provider Demographics
NPI:1194448555
Name:KESECKER, MADISEN BROOKE (LPC-R)
Entity type:Individual
Prefix:
First Name:MADISEN
Middle Name:BROOKE
Last Name:KESECKER
Suffix:
Gender:F
Credentials:LPC-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4905 DICKENS RD STE 106
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23230-1953
Mailing Address - Country:US
Mailing Address - Phone:571-550-0767
Mailing Address - Fax:804-269-5003
Practice Address - Street 1:8200 ROLLING RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22153-3110
Practice Address - Country:US
Practice Address - Phone:703-440-2180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-21
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0704015161101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health