1013559012 NPI number — GRACE HOPE COUNSELING OF FLORIDA, PLLC

Table of content: (NPI 1013559012)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013559012 NPI number — GRACE HOPE COUNSELING OF FLORIDA, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRACE HOPE COUNSELING OF FLORIDA, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
GRACE COUNSELING SERVICES OF WINTER HAVEN, PLLC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013559012
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/05/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
111 W CENTRAL AVE # 956
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINTER HAVEN
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33880-8001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
863-210-9473
Provider Business Mailing Address Fax Number:
863-588-3152

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
99 6TH ST SW STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINTER HAVEN
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33880-7902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-662-4191
Provider Business Practice Location Address Fax Number:
863-588-3152
Provider Enumeration Date:
10/10/2019

Additional Information

Authorized Official

Authorized Official Last Name:
SCOTT
Authorized Official First Name:
NAKITA
Authorized Official Middle Name:
WATKINS
Authorized Official Title or Position:
EXECUTIVE CLINICAL DIRECTOR
Authorized Official Telephone Number:
863-662-4191

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP1600X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1326315979 . This is a "LCSW" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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