MEDICARE: GRACE ABOUNDS

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1225639958
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRACE ABOUNDS

Provider Business Mailing Address
First Line	:	975 COLEY DR UNIT 1232
Second Line	:
City	:	MOUNTAIN HOME
State	:	AR
Zip	:	72654-7115
Country	:	US
Telephone Number	:	870-232-4181
Fax Number	:

Provider Business Practice Location Address
First Line	:	1219 COMMERCE DR STE 3
Second Line	:
City	:	MOUNTAIN HOME
State	:	AR
Zip	:	72653-2604
Country	:	US
Telephone Number	:	870-232-4181
Fax Number	:

Authorized Official
Title or Position	:	CEO/PRESIDENT
Name	:	DANIEL GRACE
Credential	:	LPC-S
Telephone Number	:	870-232-4181

Provider Enumeration Date	:	11/09/2020
Last Update Date	:	11/09/2020

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