Healthcare Provider Details

I. General information

NPI: 1235750753
Provider Name (Legal Business Name): HOUSE OF G.R.A.C.E.RESIDENTIAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2020
Last Update Date: 11/17/2021
Certification Date: 11/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 CLEVELAND AVE NW STE 555 SUITE 555
CANTON OH
44702-1779
US

IV. Provider business mailing address

116 CLEVELAND AVE NW SUITE 555
CANTON OH
44702-1779
US

V. Phone/Fax

Practice location:
  • Phone: 330-915-8347
  • Fax: 330-915-6030
Mailing address:
  • Phone: 330-915-8347
  • Fax: 330-915-6030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: AUDRA MARTIN
Title or Position: CEO
Credential: PHD , LISW-S
Phone: 330-915-8347