Provider Demographics
NPI:1407072770
Name:GRACE HARBOUR, INC
Entity type:Organization
Organization Name:GRACE HARBOUR, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:FREEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-934-9244
Mailing Address - Street 1:200 WESTPARK DR STE 325
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-3574
Mailing Address - Country:US
Mailing Address - Phone:770-486-1140
Mailing Address - Fax:678-669-2693
Practice Address - Street 1:200 WESTPARK DR STE 325
Practice Address - Street 2:
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-3574
Practice Address - Country:US
Practice Address - Phone:770-486-1140
Practice Address - Fax:678-669-2693
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA684485156AMedicaid
7680934OtherAETNA
600073520OtherMAGELLAN