Provider Demographics
NPI:1417658295
Name:GRACE OUT LOUD THERAPY SERVICES, LLC
Entity Type:Organization
Organization Name:GRACE OUT LOUD THERAPY SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:ANA-ALICIA
Authorized Official - Middle Name:FARRAR
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:336-926-7476
Mailing Address - Street 1:2150 SILVERSMITH CT
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-4123
Mailing Address - Country:US
Mailing Address - Phone:571-412-1006
Mailing Address - Fax:
Practice Address - Street 1:2150 SILVERSMITH CT
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-4123
Practice Address - Country:US
Practice Address - Phone:571-412-1006
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-17
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Single Specialty