Healthcare Provider Details

I. General information

NPI: 1528090016
Provider Name (Legal Business Name): LOTTIE GRACE OLSON-DAVIDSON PH.D., LPC, LCMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 05/20/2024
Certification Date: 05/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4222 FORTUNA CENTER PLZ STE 192
DUMFRIES VA
22025-1515
US

IV. Provider business mailing address

4222 FORTUNA CENTER PLZ STE 192
DUMFRIES VA
22025-1515
US

V. Phone/Fax

Practice location:
  • Phone: 703-910-7529
  • Fax: 703-910-7555
Mailing address:
  • Phone: 703-910-7529
  • Fax: 703-910-7555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number456
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4402
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberC-4523
License Number StateAK
# 4
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberNC # 9490
License Number StateNC
# 5
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPRC14303
License Number StateDC
# 6
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number9384
License Number StateSC
# 7
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCC7371
License Number StateME
# 8
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPC7218
License Number StateME
# 9
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberVA #0701005309
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: