Provider Demographics
NPI:1639483233
Name:GRACE STREET SERVICES LLC
Entity Type:Organization
Organization Name:GRACE STREET SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:OBRIEN
Authorized Official - Suffix:SR
Authorized Official - Credentials:LADC
Authorized Official - Phone:207-212-9258
Mailing Address - Street 1:105 MIDDLE ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-7037
Mailing Address - Country:US
Mailing Address - Phone:207-212-9258
Mailing Address - Fax:
Practice Address - Street 1:105 MIDDLE ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-7037
Practice Address - Country:US
Practice Address - Phone:207-212-9258
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-06
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME605962251S00000X
ME606205251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health