MEDICARE: GRACEFILLEDDC LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor
2	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1689522740
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRACEFILLEDDC LLC

Provider Business Mailing Address
First Line	:	5521 COLORADO AVE NW
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20011-7845
Country	:	US
Telephone Number	:	443-622-6572
Fax Number	:

Provider Business Practice Location Address
First Line	:	5521 COLORADO AVE NW
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20011-7845
Country	:	US
Telephone Number	:	443-622-6572
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	JANNET F MOFOR
Credential	:
Telephone Number	:	443-622-6572

Provider Enumeration Date	:	03/16/2026
Last Update Date	:	03/16/2026

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Directions to “GRACEFILLEDDC LLC ” Practice Location

Language	Start Address	Practice Location

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