Provider Demographics
NPI:1306509732
Name:GRACE CENTER FOR WELLNESS LLC
Entity type:Organization
Organization Name:GRACE CENTER FOR WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIONNEA
Authorized Official - Middle Name:
Authorized Official - Last Name:SEALS
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:312-204-7245
Mailing Address - Street 1:1 E ERIE ST STE 525-5017
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2740
Mailing Address - Country:US
Mailing Address - Phone:312-204-7245
Mailing Address - Fax:
Practice Address - Street 1:1 E ERIE ST STE 525-5017
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2740
Practice Address - Country:US
Practice Address - Phone:708-381-0327
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-21
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)