=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871291518
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRACE PSYCHIATRY, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2023
-----------------------------------------------------
Last Update Date | 02/22/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8200 GREENSBORO DR STE 900
-----------------------------------------------------
City | MC LEAN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22102-4931
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-665-9613
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8200 GREENSBORO DR STE 900
-----------------------------------------------------
City | MC LEAN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22102-4931
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-665-9613
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN ASSISTANT
-----------------------------------------------------
Name | NATASHA OLLIVER
-----------------------------------------------------
Credential | PA-C
-----------------------------------------------------
Telephone | 505-205-6397
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------