1659863256 NPI number — GRACE COUNSELING PLLC

Table of content: (NPI 1659863256)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659863256 NPI number — GRACE COUNSELING PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRACE COUNSELING 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:
Provider Other Organization Name Type Code:
6
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:
1659863256
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/31/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
110 HUBER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MADISON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39110-6983
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-955-3079
Provider Business Mailing Address Fax Number:
601-506-9724

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
598 YANDELL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANTON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39046-8846
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-506-9724
Provider Business Practice Location Address Fax Number:
601-861-4924
Provider Enumeration Date:
05/31/2018

Additional Information

Authorized Official

Authorized Official Last Name:
JONES
Authorized Official First Name:
DANA
Authorized Official Middle Name:
MICHELLE
Authorized Official Title or Position:
OWNER/COUNSELOR
Authorized Official Telephone Number:
601-955-3079

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X , with the licence number:  1287 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 03688237 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com