Provider Demographics
NPI:1124625686
Name:HOUSE, GRACE YVONNE
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:YVONNE
Last Name:HOUSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2855 LAWRENCEVILLE SUWANEE RD
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-3563
Mailing Address - Country:US
Mailing Address - Phone:770-904-3954
Mailing Address - Fax:
Practice Address - Street 1:2855 LAWRENCEVILLE SUWANEE RD
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-3563
Practice Address - Country:US
Practice Address - Phone:770-904-3954
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-07
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1053101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)