Healthcare Provider Details

I. General information

NPI: 1972953941
Provider Name (Legal Business Name): GRACEFUL WAY COUNSELING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2016
Last Update Date: 04/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1035 S STATE ROAD 7 STE 315
WELLINGTON FL
33414
US

IV. Provider business mailing address

1035 S STATE ROAD 7 STE 315
WELLINGTON FL
33414-6137
US

V. Phone/Fax

Practice location:
  • Phone: 561-571-5501
  • Fax: 561-791-8039
Mailing address:
  • Phone: 561-571-5501
  • Fax: 561-791-8039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH12300
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CELESTINE MARIE QUIROGA
Title or Position: CEO
Credential: LMHC
Phone: 561-571-5501