Provider Demographics
NPI:1528848199
Name:GRACE BEHAVIORAL HEALTH LLC
Entity type:Organization
Organization Name:GRACE BEHAVIORAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/ THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:LEANNA
Authorized Official - Middle Name:A
Authorized Official - Last Name:FOWLDS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:573-469-2433
Mailing Address - Street 1:2208 MISSOURI BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-4742
Mailing Address - Country:US
Mailing Address - Phone:573-469-2433
Mailing Address - Fax:573-550-2436
Practice Address - Street 1:57109 QUENTIN DR
Practice Address - Street 2:
Practice Address - City:CALIFORNIA
Practice Address - State:MO
Practice Address - Zip Code:65018-6000
Practice Address - Country:US
Practice Address - Phone:573-469-2433
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-02
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty