Individual
MS. GRACE A. PRUDOM
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
LCSW
Contact information
Practice address
424 HAMILTON BLVD., SOUTH BOSTON, VA 24592-0488
(434) 572-2936
(434) 572-4881
Mailing address
PO BOX 488, SOUTH BOSTON, VA 24592-0488
(434) 572-2936
(434) 572-4881
Taxonomy
Speciality
Code
Description
License number
State
1041C0700X
Clinical Social Worker
Primary
0904004773
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1700890761 - GR. NPI
—
VA
01
—
317571
ANTHEM - MECK
VA
01
—
317572
ANTHEM - HALIFAX
VA
01
—
317573
ANTHEM - BRUN
VA
01
—
O83458
SENTARA - BRUN
VA
01
—
O83458A
SENTARA - MECK
VA
01
—
O83458B
SENTARA - HALIFAX
VA
Enumeration date
12/19/2007
Last updated
12/19/2007
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