Healthcare Provider Details

I. General information

NPI: 1053935940
Provider Name (Legal Business Name): HOME OF GRACE COUNSELING SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2020
Last Update Date: 07/20/2020
Certification Date: 07/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14200 JERICHO RD
VANCLEAVE MS
39565-9771
US

IV. Provider business mailing address

PO BOX 5009
VANCLEAVE MS
39565-5009
US

V. Phone/Fax

Practice location:
  • Phone: 228-826-5283
  • Fax: 228-826-1663
Mailing address:
  • Phone: 228-826-5283
  • Fax: 228-826-1663

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
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code276400000X
TaxonomySubstance Use Disorder Rehabilitation Hospital Unit
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. JOSHUA BARTON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 228-826-6522