Provider Demographics
NPI:1316775380
Name:ABUNDANT GRACE SUPPORT SERVICES LLC
Entity type:Organization
Organization Name:ABUNDANT GRACE SUPPORT SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:TETTEH
Authorized Official - Middle Name:NII
Authorized Official - Last Name:ADDY
Authorized Official - Suffix:
Authorized Official - Credentials:DR
Authorized Official - Phone:757-268-9992
Mailing Address - Street 1:102 HUFF DR
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22554-3360
Mailing Address - Country:US
Mailing Address - Phone:540-818-4825
Mailing Address - Fax:
Practice Address - Street 1:102 HUFF DR
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22554-3360
Practice Address - Country:US
Practice Address - Phone:540-818-4825
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-22
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084B0040XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyBehavioral Neurology & NeuropsychiatryGroup - Multi-Specialty