=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508780206
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SEASONS OF GRACE CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2026
-----------------------------------------------------
Last Update Date | 08/05/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3086 RUBY LN
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38111-2936
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-315-2668
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3086 RUBY LN
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38111-2936
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-315-2668
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR, CCO
-----------------------------------------------------
Name | MS. LA TONYA EVETTE ANDERSON
-----------------------------------------------------
Credential | CPHT, BS, MBA
-----------------------------------------------------
Telephone | 901-315-2668
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320600000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 320700000X
-----------------------------------------------------
Taxonomy Name | Physical Disabilities Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------