=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023694478
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | A PLACE FOR GRACE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2021
-----------------------------------------------------
Last Update Date | 03/23/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11 S 1ST ST
-----------------------------------------------------
City | COUNCIL BLUFFS
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 51503-4315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-620-3284
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 37053 HUTCHINGS AVE
-----------------------------------------------------
City | HASTINGS
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 51540-4067
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 712-621-7300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | THERAPIST/OWNER
-----------------------------------------------------
Name | GRACE LYNE BROTHERTON
-----------------------------------------------------
Credential | LIMHP, LMHC
-----------------------------------------------------
Telephone | 515-620-3284
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------