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General NPI Number Information
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NPI Number | 1043057482
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Entity Type | Organization
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Legal Business Name | AMAZING GRACE TREATMENT CENTER, INC.
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Dates
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Enumeration Date | 07/12/2024
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Last Update Date | 07/12/2024
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Provider Practice Location Address
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Address Line | 17 INDIANA AVE
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City | DAYTON
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State | OH
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Zip | 45410-2307
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Country | US
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Telephone | 937-640-3400
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Fax |
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Provider Business Mailing Address
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Address Line | 17 INDIANA AVE
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City | DAYTON
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State | OH
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Zip | 45410-2307
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Country | US
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Telephone | 937-640-3400
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Fax |
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Authorized Official
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Title or Position | PROGRAM MANAGER
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Name | TYES'A NELLOMS
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Credential | ADN, QMHS
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Telephone | 937-231-8773
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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