Provider Demographics
NPI:1356987002
Name:TRACE, JAMES RODNEY (RN MSN)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:RODNEY
Last Name:TRACE
Suffix:
Gender:M
Credentials:RN MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2750 GALLOWS RD APT 439
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22180-7167
Mailing Address - Country:US
Mailing Address - Phone:678-923-1882
Mailing Address - Fax:
Practice Address - Street 1:3300 WOODBURN RD
Practice Address - Street 2:
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003-1202
Practice Address - Country:US
Practice Address - Phone:703-205-9452
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-18
Last Update Date:2019-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0732007969101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health