Healthcare Provider Details

I. General information

NPI: 1841808060
Provider Name (Legal Business Name): BY GRACE COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2020
Last Update Date: 07/14/2020
Certification Date: 07/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HEMINGWAY LN
ROSWELL GA
30075-7024
US

IV. Provider business mailing address

734 HEMINGWAY LN
ROSWELL GA
30075-7006
US

V. Phone/Fax

Practice location:
  • Phone: 470-765-8393
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. TISA MACKLIN-STANLEY
Title or Position: PROVIDER
Credential:
Phone: 404-827-8038