Provider Demographics
NPI:1649838285
Name:GRACE NOVA COUNSELING
Entity type:Organization
Organization Name:GRACE NOVA COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED MENTAL HEALTH COUNSELOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:LUTRELL
Authorized Official - Last Name:STEPHENSON
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC
Authorized Official - Phone:571-230-3019
Mailing Address - Street 1:8227 OLD COURTHOUSE RD STE 215
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3815
Mailing Address - Country:US
Mailing Address - Phone:571-230-3019
Mailing Address - Fax:
Practice Address - Street 1:8227 OLD COURTHOUSE RD STE 215
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22182-3815
Practice Address - Country:US
Practice Address - Phone:571-230-3019
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-29
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)