Provider Demographics
NPI:1255676011
Name:GRACE RANCH
Entity Type:Organization
Organization Name:GRACE RANCH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HARDENBROOK
Authorized Official - Suffix:
Authorized Official - Credentials:LADC, LADC-S
Authorized Official - Phone:702-370-8912
Mailing Address - Street 1:7729 MAVERICK ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89131-2113
Mailing Address - Country:US
Mailing Address - Phone:702-370-8912
Mailing Address - Fax:
Practice Address - Street 1:7729 MAVERICK ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89131-2113
Practice Address - Country:US
Practice Address - Phone:702-370-8912
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-05
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV00202-S101YA0400X
NV101YP1600X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty