Provider Demographics
NPI:1821515552
Name:WORTHINGTON, GRAE
Entity Type:Individual
Prefix:
First Name:GRAE
Middle Name:
Last Name:WORTHINGTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11609 HELMONT DR
Mailing Address - Street 2:
Mailing Address - City:OAKTON
Mailing Address - State:VA
Mailing Address - Zip Code:22124-1219
Mailing Address - Country:US
Mailing Address - Phone:703-772-3920
Mailing Address - Fax:
Practice Address - Street 1:3611 CHAIN BRIDGE RD STE C
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-3246
Practice Address - Country:US
Practice Address - Phone:703-380-9045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-23
Last Update Date:2017-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health