Healthcare Provider Details

I. General information

NPI: 1588315501
Provider Name (Legal Business Name): PEACEFUL PLACE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2022
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8133 LEESBURG PIKE STE 130
VIENNA VA
22182-2706
US

IV. Provider business mailing address

8000 TOWERS CRESCENT DR FL 13
VIENNA VA
22182-6211
US

V. Phone/Fax

Practice location:
  • Phone: 720-938-0507
  • Fax:
Mailing address:
  • Phone: 720-938-0507
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: SHANNON YOUNG
Title or Position: PSYCHOTHERAPIST/CO-OWNER
Credential: LICSW
Phone: 262-880-4039