Healthcare Provider Details

I. General information

NPI: 1407359045
Provider Name (Legal Business Name): GRACE FROM DARKNESS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2018
Last Update Date: 01/18/2024
Certification Date: 01/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 N UNIVERSITY DR STE 102A
CORAL SPRINGS FL
33071-6083
US

IV. Provider business mailing address

1515 N UNIVERSITY DR
CORAL SPRINGS FL
33071-6096
US

V. Phone/Fax

Practice location:
  • Phone: 718-872-8456
  • Fax:
Mailing address:
  • Phone: 718-872-8456
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberMH13131
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberMH13131
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH13131
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License NumberMH13131
License Number StateFL
# 5
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License NumberMH13131
License Number StateFL

VIII. Authorized Official

Name: DEYANIRA BALDERA
Title or Position: LICENSED MENTAL HEALTH COUNSELOR
Credential: LMHC
Phone: 718-872-8456