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General NPI Number Information
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NPI Number | 1144476847
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Entity Type | Organization
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Legal Business Name | GRACE COUNSELING & MEDIATION SERVICES LLC
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Dates
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Enumeration Date | 08/13/2008
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Last Update Date | 10/09/2024
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Provider Practice Location Address
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Address Line | 2875 CHEVOIT HILL CT
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City | WOODBRIDGE
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State | VA
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Zip | 22191
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Country | US
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Telephone | 703-910-7529
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Fax | 703-910-7555
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Provider Business Mailing Address
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Address Line | 4222 FORTUNA CENTER PLZ STE 192
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City | DUMFRIES
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State | VA
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Zip | 22025-1515
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Country | US
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Telephone | 703-910-7529
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. LOTTIE GRACE OLSON-DAVIDSON
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Credential | PH.D.
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Telephone | 703-910-7529
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 0701005309
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License Number State | VA
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