Provider Demographics
NPI:1750692307
Name:GRANDELA, GAIL LESLIE (LPC, CCM)
Entity type:Individual
Prefix:MRS
First Name:GAIL
Middle Name:LESLIE
Last Name:GRANDELA
Suffix:
Gender:F
Credentials:LPC, CCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 MORNINGMIST DR
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22406-7275
Mailing Address - Country:US
Mailing Address - Phone:757-748-7620
Mailing Address - Fax:
Practice Address - Street 1:3020 JAVIER RD
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4609
Practice Address - Country:US
Practice Address - Phone:757-748-7620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-29
Last Update Date:2013-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701003293101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional