{
"Npi": {
"NPI": "1043057482",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "AMAZING GRACE TREATMENT CENTER, INC.",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "17 INDIANA AVE",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "DAYTON",
"MailingAddressStateName": "OH",
"MailingAddressPostalCode": "45410-2307",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "937-640-3400",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "17 INDIANA AVE",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "DAYTON",
"PracticeLocationAddressStateName": "OH",
"PracticeLocationAddressPostalCode": "45410-2307",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "937-640-3400",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "07/12/2024",
"LastUpdateDate": "07/12/2024",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "NELLOMS",
"AuthorizedOfficialFirstName": "TYES'A",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "PROGRAM MANAGER",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "ADN, QMHS",
"AuthorizedOfficialTelephoneNumber": "937-231-8773",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "101YM0800X",
"TaxonomyName": "Mental Health Counselor",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193400000X SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}