MEDICARE: GRAPE STREET COMMUNITY RESTORATION INC.

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	101YP2500X	Professional Counselor
2	390200000X	Student in an Organized Health Care Education/Training Program
3	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1619742244
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRAPE STREET COMMUNITY RESTORATION INC.

Provider Business Mailing Address
First Line	:	10139 BEACH ST APT 26A-3
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90002-2978
Country	:	US
Telephone Number	:	323-801-6071
Fax Number	:

Provider Business Practice Location Address
First Line	:	10139 BEACH ST APT 26A-3
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90002-2978
Country	:	US
Telephone Number	:	323-801-6071
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL MENTAL HEALTH COUNSELOR
Name	:	SEBASTIAN DEE RANDOLPH
Credential	:	STUDENT COUNSELOR
Telephone Number	:	602-736-7383

Provider Enumeration Date	:	11/27/2023
Last Update Date	:	11/27/2023

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