Provider Demographics
NPI:1073270625
Name:GRAVES, SHANNON JUSTINE (LPC)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:JUSTINE
Last Name:GRAVES
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1183 N VAN DORN ST
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-1914
Mailing Address - Country:US
Mailing Address - Phone:561-271-4602
Mailing Address - Fax:
Practice Address - Street 1:520 N WASHINGTON ST STE 100
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22046-3538
Practice Address - Country:US
Practice Address - Phone:703-829-6418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-18
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701011012101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional