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General NPI Number Information
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NPI Number | 1316795701
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Entity Type | Organization
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Legal Business Name | BALANCED GRACE THERAPY PLLC
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Dates
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Enumeration Date | 05/09/2024
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Last Update Date | 05/09/2024
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Provider Practice Location Address
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Address Line | 18161 MORRIS AVE STE 207
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City | HOMEWOOD
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State | IL
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Zip | 60430-2141
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Country | US
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Telephone | 708-212-3603
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Fax |
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Provider Business Mailing Address
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Address Line | 1145 JAMIE LN
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City | HOMEWOOD
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State | IL
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Zip | 60430-4133
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Country | US
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Telephone | 708-212-3603
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | BROOKE A WILLIAMS
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Credential | LCPC
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Telephone | 708-212-3603
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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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