Provider Demographics
NPI:1265116800
Name:TOMCHICK, GRANT JUSTYN
Entity type:Individual
Prefix:
First Name:GRANT
Middle Name:JUSTYN
Last Name:TOMCHICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1964 GALLOWS RD STE 280
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3877
Mailing Address - Country:US
Mailing Address - Phone:571-533-3456
Mailing Address - Fax:
Practice Address - Street 1:1964 GALLOWS RD STE 280
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22182-3877
Practice Address - Country:US
Practice Address - Phone:571-533-3456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARBT-23-278683106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst