Healthcare Provider Details

I. General information

NPI: 1689972879
Provider Name (Legal Business Name): GRACE GARDENS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2011
Last Update Date: 03/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 N FRANKLIN ST STE 205
CUBA MO
65453-1719
US

IV. Provider business mailing address

130 REDWOOD LN
BOURBON MO
65441-7118
US

V. Phone/Fax

Practice location:
  • Phone: 314-650-3281
  • Fax: 573-885-1600
Mailing address:
  • Phone: 314-650-3281
  • Fax: 573-885-1600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number2005031753
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number2005031753
License Number StateMO

VIII. Authorized Official

Name: ANITA F MCCORMACK
Title or Position: ORGANIZER
Credential: MSW, LCSW
Phone: 314-650-3281