Healthcare Provider Details

I. General information

NPI: 1700986080
Provider Name (Legal Business Name): GRACE COUNSELING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 09/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1125 HEATHERSTONE DRIVE SUITE 101
FREDERICKSBURG VA
22407
US

IV. Provider business mailing address

1125 HEATHERSTONE DRIVE SUITE 101
FREDERICKSBURG VA
22407
US

V. Phone/Fax

Practice location:
  • Phone: 540-548-4114
  • Fax: 540-548-2541
Mailing address:
  • Phone: 540-548-4114
  • Fax: 540-548-2541

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701003590
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number0717001031
License Number StateVA

VIII. Authorized Official

Name: MR. JEFFREY SUMPOLEC
Title or Position: DIRECTOR
Credential: LPC
Phone: 540-548-4114