Healthcare Provider Details

I. General information

NPI: 1245847524
Provider Name (Legal Business Name): GRACELAND STUDENT SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2020
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 FAIRVIEW AVE.
WILSON NC
27893
US

IV. Provider business mailing address

P.O. BOX 31
WILSON NC
27894
US

V. Phone/Fax

Practice location:
  • Phone: 919-593-7324
  • Fax:
Mailing address:
  • Phone: 919-593-7324
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. KRYSTLE M. JOHNSON
Title or Position: CO-OWNER
Credential:
Phone: 919-593-7324