MEDICARE: AMAZING GRACE TREATMENT CENTER, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor
2	320800000X	Mental Illness Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1043057482
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AMAZING GRACE TREATMENT CENTER, INC.

Provider Business Mailing Address
First Line	:	17 INDIANA AVE
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45410-2307
Country	:	US
Telephone Number	:	937-640-3400
Fax Number	:

Provider Business Practice Location Address
First Line	:	17 INDIANA AVE
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45410-2307
Country	:	US
Telephone Number	:	937-640-3400
Fax Number	:

Authorized Official
Title or Position	:	PROGRAM MANAGER
Name	:	TYES'A NELLOMS
Credential	:	ADN, QMHS
Telephone Number	:	937-231-8773

Provider Enumeration Date	:	07/12/2024
Last Update Date	:	03/23/2026

Similar Medicare Providers

1124960653 — AMAZING GRACE TREATMENT CENTER THERAPEUTIC CARE, LLC.
Practice Location Address:

17 INDIANA AVE
DAYTON, OH
45410-2307

Practice Phone: 937-231-8773
Practice Fax:

1477398428 — KAMRYN CAMPBELL
Practice Location Address:

2307 RUSTIC RD
DAYTON, OH
45406-2137

Practice Phone: 937-830-8513
Practice Fax:

1578282737 — LATIA NORRIS
Practice Location Address:

600 WAYNE AVE
DAYTON, OH
45410-1122

Practice Phone: 937-496-2000
Practice Fax:

1942900451 — JUSTIN MCLAUGHLIN
Practice Location Address:

600 WAYNE AVE
DAYTON, OH
45410-1199

Practice Phone: 937-496-2000
Practice Fax:

1467251561 — AMY MURAN
Practice Location Address:

526 XENIA AVE
DAYTON, OH
45410-1824

Practice Phone: 937-949-1524
Practice Fax:

1922001221 — THE FOUNTAINVIEW
Practice Location Address:

250 PARK DR
DAYTON, OH
45410-1316

Practice Phone: 216-661-6800
Practice Fax: 216-739-3789

Directions to “AMAZING GRACE TREATMENT CENTER, INC. ” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

Copyright © 2007-2026 (Powered by Swiss Vault Engine), all rights reserved. HIPAA liability, trademark, document use and software licensing rules apply. All registered trademarks, used in the content, are the property of their owners. Your interactions with this site are in accordance with our Terms of Use and Privacy Policy.