Provider Demographics
NPI:1356833974
Name:GRACE ABA LLC
Entity Type:Organization
Organization Name:GRACE ABA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BCBA
Authorized Official - Prefix:
Authorized Official - First Name:LYNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:719-459-8374
Mailing Address - Street 1:372 BELGRAVE RD
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23602-6403
Mailing Address - Country:US
Mailing Address - Phone:719-459-8374
Mailing Address - Fax:757-282-2597
Practice Address - Street 1:372 BELGRAVE RD
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602-6403
Practice Address - Country:US
Practice Address - Phone:719-459-8374
Practice Address - Fax:757-282-2597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-30
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0133000785103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA=========OtherBEHAVIOR ANALYST