Healthcare Provider Details

I. General information

NPI: 1437766375
Provider Name (Legal Business Name): GRACE BEHAVIORAL HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2020
Last Update Date: 08/29/2023
Certification Date: 08/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 BURNT TAVERN RD STE 1A
BRICK NJ
08724-1496
US

IV. Provider business mailing address

PO BOX 46
LAKEHURST NJ
08733-0046
US

V. Phone/Fax

Practice location:
  • Phone: 908-417-0632
  • Fax:
Mailing address:
  • Phone: 908-417-0632
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: OMEZIE MOLOKWU
Title or Position: PRESIDENT
Credential: APN
Phone: 908-417-0632