MEDICARE: AMAZING GRACE TREATMENT CENTER THERAPEUTIC CARE, LLC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	261QM0855X	Adolescent and Children Mental Health Clinic/Center
2	251S00000X	Community/Behavioral Health Agency
3	251B00000X	Case Management Agency

General Provider Information

NPI Number	:	1124960653
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AMAZING GRACE TREATMENT CENTER THERAPEUTIC CARE, LLC.

Provider Business Mailing Address
First Line	:	330 W 1ST ST APT 905
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45402-3055
Country	:	US
Telephone Number	:	937-231-8773
Fax Number	:

Provider Business Practice Location Address
First Line	:	17 INDIANA AVE
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45410-2307
Country	:	US
Telephone Number	:	937-231-8773
Fax Number	:

Authorized Official
Title or Position	:	PROGRAM MANAGER
Name	:	MS. TYES'A NELLOMS
Credential	:	QMHS, ADN
Telephone Number	:	937-231-8773

Provider Enumeration Date	:	04/06/2026
Last Update Date	:	04/06/2026

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