Healthcare Provider Details

I. General information

NPI: 1124960653
Provider Name (Legal Business Name): AMAZING GRACE TREATMENT CENTER THERAPEUTIC CARE, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2026
Last Update Date: 04/06/2026
Certification Date: 03/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 INDIANA AVE
DAYTON OH
45410-2307
US

IV. Provider business mailing address

330 W 1ST ST APT 905
DAYTON OH
45402-3055
US

V. Phone/Fax

Practice location:
  • Phone: 937-231-8773
  • Fax:
Mailing address:
  • Phone: 937-231-8773
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. TYES'A NELLOMS
Title or Position: PROGRAM MANAGER
Credential: QMHS, ADN
Phone: 937-231-8773