Healthcare Provider Details

I. General information

NPI: 1851843940
Provider Name (Legal Business Name): GRACE BEHAVIORAL SUPPORT SERVICES FL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2016
Last Update Date: 10/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

780 FISHERMAN ST STE 210
OPA LOCKA FL
33054-3807
US

IV. Provider business mailing address

780 FISHERMAN ST STE 250
OPA LOCKA FL
33054-3807
US

V. Phone/Fax

Practice location:
  • Phone: 305-681-2500
  • Fax: 305-681-2525
Mailing address:
  • Phone: 305-681-2500
  • Fax: 305-681-2525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name: MS. CHANTALE MILORD-FERGUSON
Title or Position: DIRECTOR
Credential:
Phone: 786-508-4148