Healthcare Provider Details

I. General information

NPI: 1205762069
Provider Name (Legal Business Name): GRACE PATH WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2026
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1747 TYSONS CENTRAL ST APT 2302
TYSONS VA
22182-6057
US

IV. Provider business mailing address

5709 EDGEWOOD AVE
LYNCHBURG VA
24502-1903
US

V. Phone/Fax

Practice location:
  • Phone: 925-775-8253
  • Fax:
Mailing address:
  • Phone: 925-775-8253
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MARCEL GRISARD
Title or Position: OWNER
Credential:
Phone: 925-775-8253