Provider Demographics
NPI:1013605401
Name:GROVE, MADELINE R
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:R
Last Name:GROVE
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 1:4094 MAJESTIC LN # 237
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-2104
Mailing Address - Country:US
Mailing Address - Phone:571-377-8114
Mailing Address - Fax:
Practice Address - Street 1:1205 DOLLEY MADISON BLVD
Practice Address - Street 2:
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-3019
Practice Address - Country:US
Practice Address - Phone:571-377-8114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-25
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0704014970101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health