MEDICARE: ABUNDANT GRACE ADULT & YOUTH SERVICES

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	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1336719640
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ABUNDANT GRACE ADULT & YOUTH SERVICES

Provider Business Mailing Address
First Line	:	8430 W CAPITOL DR
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53222-1846
Country	:	US
Telephone Number	:	414-462-0750
Fax Number	:

Provider Business Practice Location Address
First Line	:	8430 W CAPITOL DR
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53222-1846
Country	:	US
Telephone Number	:	414-462-0750
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MS. JOCELYN WRIGHT HALL
Credential	:	PHD (ABD)
Telephone Number	:	414-248-9271

Provider Enumeration Date	:	06/29/2021
Last Update Date	:	06/29/2021

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