Healthcare Provider Details

I. General information

NPI: 1770594442
Provider Name (Legal Business Name): DIANE LYNN BRACE M.S.W., L.C.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14150 PARKEAST CIR SUITE 200
CHANTILLY VA
20151-2295
US

IV. Provider business mailing address

5424 BRADDOCK RIDGE DR
CENTREVILLE VA
20120-3313
US

V. Phone/Fax

Practice location:
  • Phone: 703-968-4036
  • Fax: 703-263-1724
Mailing address:
  • Phone: 703-830-5378
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904001929
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: