Healthcare Provider Details

I. General information

NPI: 1992457139
Provider Name (Legal Business Name): ELIZABETH BROOKS FRASER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2022
Last Update Date: 01/19/2022
Certification Date: 01/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7051 HEATHCOTE VILLAGE WAY
GAINESVILLE VA
20155-3196
US

IV. Provider business mailing address

125 MARKET ST APT 306
MANASSAS PARK VA
20111-3216
US

V. Phone/Fax

Practice location:
  • Phone: 703-621-7121
  • Fax:
Mailing address:
  • Phone: 540-497-1637
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number090413486
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: