Healthcare Provider Details

I. General information

NPI: 1336710979
Provider Name (Legal Business Name): GIVE GRACE YOUTH & FAMILY COUNSELING, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2021
Last Update Date: 02/22/2023
Certification Date: 02/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 OLD MILL CIR STE A
WINSTON SALEM NC
27103-2977
US

IV. Provider business mailing address

1400 OLD MILL CIR STE A
WINSTON SALEM NC
27103-2977
US

V. Phone/Fax

Practice location:
  • Phone: 336-893-7742
  • Fax:
Mailing address:
  • Phone: 336-893-7742
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BROCK M GRACE
Title or Position: OWNER & MANAGING MEMBER
Credential: MS, LCMHC
Phone: 336-624-7866