Provider Demographics
NPI:1902628126
Name:GIACOBONE, KHILIA TYESE (PHD, LPC, CSOTP)
Entity type:Individual
Prefix:DR
First Name:KHILIA
Middle Name:TYESE
Last Name:GIACOBONE
Suffix:
Gender:F
Credentials:PHD, LPC, CSOTP
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 337
Mailing Address - Street 2:
Mailing Address - City:MECHANICSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23111-0337
Mailing Address - Country:US
Mailing Address - Phone:804-306-1790
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 337
Practice Address - Street 2:
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23111-0337
Practice Address - Country:US
Practice Address - Phone:804-306-1790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-29
Last Update Date:2025-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPRC15359101YP2500X
VA0701011919101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional