MEDICARE: THE GRACE SPACE COUNSELING AND WELLNESS 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	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1750251112
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE GRACE SPACE COUNSELING AND WELLNESS LLC

Provider Business Mailing Address
First Line	:	1700 NORTHSIDE DR NW STE A7
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30318-2695
Country	:	US
Telephone Number	:	470-632-4799
Fax Number	:

Provider Business Practice Location Address
First Line	:	1933 SHAWN WAYNE CIRCLE SE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30316
Country	:	US
Telephone Number	:	470-632-4799
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DE'LEON MARTIN
Credential	:	LPC
Telephone Number	:	470-632-4799

Provider Enumeration Date	:	11/10/2025
Last Update Date	:	12/02/2025

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