Provider Demographics
NPI:1477215390
Name:LIVING BY GRACE BT CORP
Entity Type:Organization
Organization Name:LIVING BY GRACE BT CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNANDEZ MENDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:786-560-8559
Mailing Address - Street 1:312 S OLD DIXIE HWY STE 202
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-7489
Mailing Address - Country:US
Mailing Address - Phone:786-560-8559
Mailing Address - Fax:
Practice Address - Street 1:312 S OLD DIXIE HWY STE 202
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-7489
Practice Address - Country:US
Practice Address - Phone:786-560-8559
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-07
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105309600Medicaid