Provider Demographics
NPI:1528201647
Name:GRACE HOUSE PA
Entity Type:Organization
Organization Name:GRACE HOUSE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:MOREY
Authorized Official - Suffix:
Authorized Official - Credentials:MED, MA, LMHC
Authorized Official - Phone:904-269-0886
Mailing Address - Street 1:1724 VILLAGE WAY
Mailing Address - Street 2:SUITE A
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-5264
Mailing Address - Country:US
Mailing Address - Phone:904-269-0886
Mailing Address - Fax:904-269-0499
Practice Address - Street 1:1724 VILLAGE WAY
Practice Address - Street 2:SUITE A
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-5264
Practice Address - Country:US
Practice Address - Phone:904-269-0886
Practice Address - Fax:904-269-0499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-20
Last Update Date:2009-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH7812101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty