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NPI Code Detail

MEDICARE: GRACES ROOM LLC

MEDICARE: GRACES ROOM 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
1363LP0808XPsychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number : 1922966746
Entity Type Code : Organization
Provider Name (Legal Business Name) : GRACES ROOM LLC
Provider Business Mailing Address
First Line : 3030 GREENMOUNT AVE STE 300
Second Line :
City : BALTIMORE
State : MD
Zip : 21218-6907
Country : US
Telephone Number : 240-203-7448
Fax Number : 240-371-0557
Provider Business Practice Location Address
First Line : 10216 INDIAN SUMMER CT
Second Line :
City : BOWIE
State : MD
Zip : 20721-3178
Country : US
Telephone Number : 240-203-7448
Fax Number : 240-371-0557
Authorized Official
Title or Position : OWNER OF ENTITY
Name : MICHAEL DICKSON
Credential : DNP
Telephone Number : 240-203-7448
Provider Enumeration Date : 01/12/2026
Last Update Date : 01/12/2026

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Directions to “GRACES ROOM LLC ” Practice Location

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