Healthcare Provider Details

I. General information

NPI: 1679806830
Provider Name (Legal Business Name): GRACE COUNSELING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2009
Last Update Date: 09/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 1ST ST N #209
SAINT CLOUD MN
56303-4256
US

IV. Provider business mailing address

2700 1ST ST N #209
SAINT CLOUD MN
56303-4256
US

V. Phone/Fax

Practice location:
  • Phone: 320-202-9107
  • Fax:
Mailing address:
  • Phone: 320-202-9107
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC00366
License Number StateMN

VIII. Authorized Official

Name: BARBARA GAY BACKES
Title or Position: OWNER
Credential: LPC, P.A., M.S.
Phone: 320-202-9107