Healthcare Provider Details

I. General information

NPI: 1114526548
Provider Name (Legal Business Name): ESSENTIAL GRACE THERAPY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2020
Last Update Date: 11/04/2020
Certification Date: 11/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12390 SHERBURNE AVE STE 210
BECKER MN
55308-9147
US

IV. Provider business mailing address

24910 184TH ST NW
BIG LAKE MN
55309-9788
US

V. Phone/Fax

Practice location:
  • Phone: 763-291-0468
  • Fax:
Mailing address:
  • Phone: 763-291-0468
  • Fax:

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 Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. JODI ANN SMITH
Title or Position: OWNER
Credential: MS, LMFT
Phone: 763-291-0468