Grace A. Prudom, LCSW

Primary specialty

Clinical Social WorkerTaxonomy code 1041C0700X

License

0904004773 Issued in VA

Practice address

424 Hamilton Blvd.
South Boston, VA 24592-0488

Phone

(434) 572-2936

Fax

(434) 572-4881

NPI assigned

Dec 19, 2007

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 7

Other names 1

• Grace A. Lebarbe Former name

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Southside Behavioral Health

  • Community/Behavioral Health Agency
  • Clarksville, VA
  • NPI 1700890761

  Clinical

  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1198022400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1198022400000",
    "number": "1891979308",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 488",
            "city": "SOUTH BOSTON",
            "state": "VA",
            "postal_code": "245920488",
            "telephone_number": "434-572-2936",
            "fax_number": "434-572-4881"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "424 HAMILTON BLVD.",
            "city": "SOUTH BOSTON",
            "state": "VA",
            "postal_code": "245920488",
            "telephone_number": "434-572-2936",
            "fax_number": "434-572-4881"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PRUDOM",
        "first_name": "GRACE",
        "middle_name": "A.",
        "name_prefix": "Ms.",
        "credential": "LCSW",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2007-12-19",
        "last_updated": "2007-12-19",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "VA",
            "license": "0904004773",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "ANTHEM - HALIFAX",
            "identifier": "317572",
            "state": "VA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1700890761 - GR. NPI",
            "state": "VA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "SENTARA -  MECK",
            "identifier": "O83458A",
            "state": "VA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "SENTARA - HALIFAX",
            "identifier": "O83458B",
            "state": "VA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "ANTHEM - MECK",
            "identifier": "317571",
            "state": "VA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "ANTHEM - BRUN",
            "identifier": "317573",
            "state": "VA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "SENTARA - BRUN",
            "identifier": "O83458",
            "state": "VA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "GRACE",
            "last_name": "LEBARBE",
            "middle_name": "A.",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

• Positive Pathways Counseling and Behavioral Health Services, LLC
• Robyn Talley Pottage, LPTA
• Carlos Alberto Pottinger, M.D.
• Priscilla Guill Powell, COTA
• James H Priest
• Ronald Pryor
• Lovetta Pugh, MD
• Pulmonary Associates of Southside Virginia, Inc
• Edward Sanford Purvis II, M.D.
• Kortney Nicole Puryear, COTA/L

• Clinical Social Worker in South Boston, VA
• Providers in South Boston, VA by specialty
• Clinical Social Worker in Virginia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 19, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.