=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124960653
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AMAZING GRACE TREATMENT CENTER THERAPEUTIC CARE, LLC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/06/2026
-----------------------------------------------------
Last Update Date | 04/06/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17 INDIANA AVE
-----------------------------------------------------
City | DAYTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45410-2307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-231-8773
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 330 W 1ST ST APT 905
-----------------------------------------------------
City | DAYTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45402-3055
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-231-8773
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROGRAM MANAGER
-----------------------------------------------------
Name | MS. TYES'A NELLOMS
-----------------------------------------------------
Credential | QMHS, ADN
-----------------------------------------------------
Telephone | 937-231-8773
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------