Healthcare Provider Details

I. General information

NPI: 1316537160
Provider Name (Legal Business Name): EXTENSION OF GRACE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2021
Last Update Date: 01/28/2021
Certification Date: 01/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4615 CHADWICK RD
CEDAR FALLS IA
50613-8090
US

IV. Provider business mailing address

4512 QUESADA CT
CEDAR FALLS IA
50613-6337
US

V. Phone/Fax

Practice location:
  • Phone: 319-255-5660
  • Fax: 319-237-7639
Mailing address:
  • Phone: 319-240-3021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: HAYLEY DOWNEY
Title or Position: OWNER
Credential:
Phone: 319-214-0264