Healthcare Provider Details

I. General information

NPI: 1447538442
Provider Name (Legal Business Name): GRACE KEIKO NOZAKI LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: GRACE T NOZAKI LCSW

II. Dates (important events)

Enumeration Date: 07/26/2011
Last Update Date: 09/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 CAMERON GLEN DR STE 600
RESTON VA
20190-3343
US

IV. Provider business mailing address

11021 CLARA BARTON DR
FAIRFAX STATION VA
22039-1406
US

V. Phone/Fax

Practice location:
  • Phone: 703-481-4153
  • Fax: 703-435-1961
Mailing address:
  • Phone: 703-593-3157
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904006574
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: