Provider Demographics
NPI:1477025534
Name:GRACE RECOVERY CENTER
Entity Type:Organization
Organization Name:GRACE RECOVERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LASHONE
Authorized Official - Middle Name:
Authorized Official - Last Name:ARNETT
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:973-769-3699
Mailing Address - Street 1:52 ELBERON AVE
Mailing Address - Street 2:
Mailing Address - City:PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07502-2025
Mailing Address - Country:US
Mailing Address - Phone:973-769-3699
Mailing Address - Fax:
Practice Address - Street 1:40 GALESI DR STE 26
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-4841
Practice Address - Country:US
Practice Address - Phone:973-769-3699
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-28
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1407204415Medicaid