Provider Demographics
NPI:1164293171
Name:LIVEWELL BEHAVIORAL HEALTH
Entity Type:Organization
Organization Name:LIVEWELL BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TANISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRACEY
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:202-277-9687
Mailing Address - Street 1:15000 POTOMAC TOWN PL, SUITE 100
Mailing Address - Street 2:#506
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2135 ABBOTTSBURY WAY
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-4098
Practice Address - Country:US
Practice Address - Phone:202-277-9687
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-10
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical