MEDICARE: GRACE HE LCMHCA

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	A19970	NC

General Provider Information

NPI Number	:	1457183113
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRACE HE LCMHCA

Provider Business Mailing Address
First Line	:	883 WASHINGTON ST STE B
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27605-3251
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	883 WASHINGTON ST STE B
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27605-3251
Country	:	US
Telephone Number	:	419-504-8121
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/20/2024
Last Update Date	:	08/20/2024

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