Healthcare Provider Details

I. General information

NPI: 1801713664
Provider Name (Legal Business Name): GRACE LILLIAN BOMAR MED
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2026
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 N WASHINGTON ST STE 100
FALLS CHURCH VA
22046-3538
US

IV. Provider business mailing address

520 N WASHINGTON ST STE 100
FALLS CHURCH VA
22046-3538
US

V. Phone/Fax

Practice location:
  • Phone: 571-286-5491
  • Fax:
Mailing address:
  • Phone: 571-286-5491
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0704019165
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: