Provider Demographics
NPI:1568079440
Name:GRACEFULLY FULFILLED COUNSELING AND COACHING SERVICES
Entity Type:Organization
Organization Name:GRACEFULLY FULFILLED COUNSELING AND COACHING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:CHRISTIAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:HOWARD
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:404-645-6289
Mailing Address - Street 1:712 H ST NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20002-3627
Mailing Address - Country:US
Mailing Address - Phone:202-952-1302
Mailing Address - Fax:202-684-2879
Practice Address - Street 1:219 56TH PLACE NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20019
Practice Address - Country:US
Practice Address - Phone:202-952-1302
Practice Address - Fax:202-684-2879
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CL ENTERPRISE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-09-25
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC1003456419Medicaid