Provider Demographics
NPI:1619742244
Name:GRAPE STREET COMMUNITY RESTORATION INC.
Entity Type:Organization
Organization Name:GRAPE STREET COMMUNITY RESTORATION INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL MENTAL HEALTH COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:SEBASTIAN
Authorized Official - Middle Name:DEE
Authorized Official - Last Name:RANDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:STUDENT COUNSELOR
Authorized Official - Phone:602-736-7383
Mailing Address - Street 1:10139 BEACH ST APT 26A-3
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90002-2978
Mailing Address - Country:US
Mailing Address - Phone:323-801-6071
Mailing Address - Fax:
Practice Address - Street 1:10139 BEACH ST APT 26A-3
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90002-2978
Practice Address - Country:US
Practice Address - Phone:323-801-6071
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty