Healthcare Provider Details

I. General information

NPI: 1851826531
Provider Name (Legal Business Name): GRACE MOORE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2017
Last Update Date: 06/25/2024
Certification Date: 06/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8221 WILLOW OAKS CORPORATE DR
FAIRFAX VA
22031-4512
US

IV. Provider business mailing address

8221 WILLOW OAKS CORPORATE DR
FAIRFAX VA
22031-4512
US

V. Phone/Fax

Practice location:
  • Phone: 703-559-3000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC200002782
License Number StateDC
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904016165
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: