MEDICARE: GRATEFUL GUIDANCE LLC

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1689330672
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRATEFUL GUIDANCE LLC

Provider Business Mailing Address
First Line	:	1005 W STATE ROAD 84
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33315-2433
Country	:	US
Telephone Number	:	754-900-8280
Fax Number	:	949-862-3411

Provider Business Practice Location Address
First Line	:	1005 W STATE ROAD 84
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33315-2433
Country	:	US
Telephone Number	:	754-900-8280
Fax Number	:	949-862-3411

Authorized Official
Title or Position	:	OWNER
Name	:	TIFFANY CHAMBERS
Credential	:	LPC
Telephone Number	:	754-900-8280

Provider Enumeration Date	:	11/13/2021
Last Update Date	:	11/13/2021

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Directions to “GRATEFUL GUIDANCE LLC ” Practice Location

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