Provider Demographics
NPI:1497151484
Name:AMAZING GRACE COUNSELING SERVICES, PLLC
Entity Type:Organization
Organization Name:AMAZING GRACE COUNSELING SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:NECOLE
Authorized Official - Middle Name:W
Authorized Official - Last Name:FRYAR
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC
Authorized Official - Phone:210-883-6287
Mailing Address - Street 1:9830 APPELLATE WAY
Mailing Address - Street 2:
Mailing Address - City:CONVERSE
Mailing Address - State:TX
Mailing Address - Zip Code:78109-1985
Mailing Address - Country:US
Mailing Address - Phone:210-883-6287
Mailing Address - Fax:210-305-5750
Practice Address - Street 1:9830 APPELLATE WAY
Practice Address - Street 2:
Practice Address - City:CONVERSE
Practice Address - State:TX
Practice Address - Zip Code:78109-1985
Practice Address - Country:US
Practice Address - Phone:210-883-6287
Practice Address - Fax:210-305-5750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-18
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX66851261QM0801X, 261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3455909-01Medicaid