Healthcare Provider Details

I. General information

NPI: 1184330821
Provider Name (Legal Business Name): GRATEFUL BEGINNINGS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2023
Last Update Date: 05/21/2025
Certification Date: 05/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11321 WALTON LAKE RD
DISPUTANTA VA
23842-4510
US

IV. Provider business mailing address

11321 WALTON LAKE RD
DISPUTANTA VA
23842-4510
US

V. Phone/Fax

Practice location:
  • Phone: 804-930-3280
  • Fax:
Mailing address:
  • Phone: 804-930-3280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: TYESHA SHAW
Title or Position: PROGRAM DIRECTOR
Credential:
Phone: 804-930-3280