Provider Demographics
NPI:1528325610
Name:REJUVENATE WITH GRACE, INC.
Entity type:Organization
Organization Name:REJUVENATE WITH GRACE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:RUTH
Authorized Official - Middle Name:LYNNE
Authorized Official - Last Name:GRACE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:321-759-4325
Mailing Address - Street 1:PO BOX 561248
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32956-1248
Mailing Address - Country:US
Mailing Address - Phone:321-759-4325
Mailing Address - Fax:321-632-1753
Practice Address - Street 1:130 N TROPICAL TRL
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-4737
Practice Address - Country:US
Practice Address - Phone:321-759-4325
Practice Address - Fax:321-632-1753
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-13
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL60891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty