=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972376846
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRACIOUS BAY COUNSELING PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2023
-----------------------------------------------------
Last Update Date | 11/02/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2 COLUMBIA RD STE 11
-----------------------------------------------------
City | PEMBROKE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02359-1842
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-630-1177
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2 CLINTON TER
-----------------------------------------------------
City | KINGSTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02364-1330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-630-1177
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | JENNIFER MURRAY
-----------------------------------------------------
Credential | OWNER
-----------------------------------------------------
Telephone | 781-630-1177
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------