=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528848199
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRACE BEHAVIORAL HEALTH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2023
-----------------------------------------------------
Last Update Date | 10/02/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 57109 QUENTIN DR
-----------------------------------------------------
City | CALIFORNIA
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65018-6000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-469-2433
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2208 MISSOURI BLVD STE 102
-----------------------------------------------------
City | JEFFERSON CITY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65109-4742
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-469-2433
-----------------------------------------------------
Fax | 573-550-2436
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR/ THERAPIST
-----------------------------------------------------
Name | LEANNA A FOWLDS
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 573-469-2433
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------