MEDICARE: ABUNDANTLY GRACED COMMUNITY SUPPORTIVE SERVICES INC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	385HR2060X	Child Intellectual and/or Developmental Disabilities Respite Care
2	251B00000X	Case Management Agency
3	253Z00000X	In Home Supportive Care Agency
4	372600000X	Adult Companion
5	101YA0400X	Addiction (Substance Use Disorder) Counselor
6	251S00000X	Community/Behavioral Health Agency
7	251E00000X	Home Health Agency
8	174200000X	Meals Provider
9	101YM0800X	Mental Health Counselor
10	175T00000X	Peer Specialist

General Provider Information

NPI Number	:	1053275206
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ABUNDANTLY GRACED COMMUNITY SUPPORTIVE SERVICES INC

Provider Business Mailing Address
First Line	:	5736 N TRYON ST STE 125A
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28213-6886
Country	:	US
Telephone Number	:	704-713-5652
Fax Number	:

Provider Business Practice Location Address
First Line	:	5736 N TRYON ST STE 125A
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28213-6886
Country	:	US
Telephone Number	:	704-713-5652
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	LASTARRA SHAWNTA MCDONALD
Credential	:
Telephone Number	:	704-819-1965

Provider Enumeration Date	:	12/11/2025
Last Update Date	:	03/11/2026

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