Healthcare Provider Details

I. General information

NPI: 1174472005
Provider Name (Legal Business Name): GRACE THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2026
Last Update Date: 01/23/2026
Certification Date: 01/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

172 YOUNG AVE
NETTLETON MS
38858-6010
US

IV. Provider business mailing address

432 ROAD 1203
NETTLETON MS
38858-8283
US

V. Phone/Fax

Practice location:
  • Phone: 662-591-1030
  • Fax:
Mailing address:
  • Phone: 662-591-1030
  • Fax: 662-591-1030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: DEBORRA CASSANDRA RIKARD
Title or Position: OWNER
Credential: LPC
Phone: 662-591-1030