Provider Demographics
NPI:1891979308
Name:PRUDOM, GRACE A (LCSW)
Entity Type:Individual
Prefix:MS
First Name:GRACE
Middle Name:A
Last Name:PRUDOM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:GRACE
Other - Middle Name:A
Other - Last Name:LEBARBE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 488
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:VA
Mailing Address - Zip Code:24592-0488
Mailing Address - Country:US
Mailing Address - Phone:434-572-2936
Mailing Address - Fax:434-572-4881
Practice Address - Street 1:424 HAMILTON BLVD.
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592-0488
Practice Address - Country:US
Practice Address - Phone:434-572-2936
Practice Address - Fax:434-572-4881
Is Sole Proprietor?:No
Enumeration Date:2007-12-19
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040047731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA317572OtherANTHEM - HALIFAX
VA1700890761 - GR. NPIMedicaid
VAO83458AOtherSENTARA - MECK
VAO83458BOtherSENTARA - HALIFAX
VA317571OtherANTHEM - MECK
VA317573OtherANTHEM - BRUN
VAO83458OtherSENTARA - BRUN
VAO83458AOtherSENTARA - MECK