Provider Demographics
NPI:1821561911
Name:GRACE THERAPY SERVICES, LLC
Entity Type:Organization
Organization Name:GRACE THERAPY SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:NOELLE
Authorized Official - Last Name:MARTIN-CUELLAR
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LMFT
Authorized Official - Phone:575-571-7499
Mailing Address - Street 1:972 VILLARRICA ST NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-2995
Mailing Address - Country:US
Mailing Address - Phone:575-571-7499
Mailing Address - Fax:
Practice Address - Street 1:972 VILLARRICA ST NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120-2995
Practice Address - Country:US
Practice Address - Phone:575-571-7499
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-10
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1366766339Medicaid