Provider Demographics
NPI:1689972879
Name:GRACE GARDENS, LLC
Entity Type:Organization
Organization Name:GRACE GARDENS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORGANIZER
Authorized Official - Prefix:
Authorized Official - First Name:ANITA
Authorized Official - Middle Name:F
Authorized Official - Last Name:MCCORMACK
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LCSW
Authorized Official - Phone:314-650-3281
Mailing Address - Street 1:130 REDWOOD LN
Mailing Address - Street 2:
Mailing Address - City:BOURBON
Mailing Address - State:MO
Mailing Address - Zip Code:65441-7118
Mailing Address - Country:US
Mailing Address - Phone:314-650-3281
Mailing Address - Fax:573-885-1600
Practice Address - Street 1:412 N FRANKLIN ST
Practice Address - Street 2:STE 205
Practice Address - City:CUBA
Practice Address - State:MO
Practice Address - Zip Code:65453-1719
Practice Address - Country:US
Practice Address - Phone:314-650-3281
Practice Address - Fax:573-885-1600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-11
Last Update Date:2011-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005031753261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1891830477OtherINDIVIDUAL NPI