Provider Demographics
NPI:1619255338
Name:EXTENDED GRACE COUNSELING, LLC
Entity Type:Organization
Organization Name:EXTENDED GRACE COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PROFESSIONAL COUNSELOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:404-427-7321
Mailing Address - Street 1:2330 SCENIC HIGHWAY SOUTH,
Mailing Address - Street 2:SUITE 313
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-3115
Mailing Address - Country:US
Mailing Address - Phone:678-892-6969
Mailing Address - Fax:770-785-7250
Practice Address - Street 1:2330 SCENIC HIGHWAY SOUTH
Practice Address - Street 2:SUITE 313
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-3115
Practice Address - Country:US
Practice Address - Phone:678-892-6969
Practice Address - Fax:770-785-7250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-29
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
GALPC004880251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty