Provider Demographics
NPI:1154024966
Name:LAUREL GRACE MENTAL HEALTH AND WELLNESS
Entity type:Organization
Organization Name:LAUREL GRACE MENTAL HEALTH AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LALENCIA
Authorized Official - Middle Name:L
Authorized Official - Last Name:MATTHEWS
Authorized Official - Suffix:
Authorized Official - Credentials:MSN
Authorized Official - Phone:612-388-4661
Mailing Address - Street 1:9614 TRONCAIS CIR
Mailing Address - Street 2:
Mailing Address - City:THONOTOSASSA
Mailing Address - State:FL
Mailing Address - Zip Code:33592-3412
Mailing Address - Country:US
Mailing Address - Phone:612-388-4661
Mailing Address - Fax:
Practice Address - Street 1:9614 TRONCAIS CIR
Practice Address - Street 2:
Practice Address - City:THONOTOSASSA
Practice Address - State:FL
Practice Address - Zip Code:33592-3412
Practice Address - Country:US
Practice Address - Phone:612-388-4661
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-22
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty