Healthcare Provider Details

I. General information

NPI: 1417658295
Provider Name (Legal Business Name): GRACE OUT LOUD THERAPY SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2023
Last Update Date: 03/17/2023
Certification Date: 03/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2150 SILVERSMITH CT
WOODBRIDGE VA
22191-4123
US

IV. Provider business mailing address

2150 SILVERSMITH CT
WOODBRIDGE VA
22191-4123
US

V. Phone/Fax

Practice location:
  • Phone: 571-412-1006
  • Fax:
Mailing address:
  • Phone: 571-412-1006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ANA-ALICIA FARRAR BROWN
Title or Position: CLINICAL SOCIAL WORKER
Credential: LICSW
Phone: 336-926-7476