Provider Demographics
NPI:1821584657
Name:AMAZING GRACE RECOVERY SERVICES, LLC
Entity Type:Organization
Organization Name:AMAZING GRACE RECOVERY SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LEADENS
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LADC
Authorized Official - Phone:651-343-3670
Mailing Address - Street 1:35619 HELIUM ST NW
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:MN
Mailing Address - Zip Code:55371-4791
Mailing Address - Country:US
Mailing Address - Phone:651-343-3670
Mailing Address - Fax:
Practice Address - Street 1:23671 SAINT FRANCIS BLVD NW
Practice Address - Street 2:
Practice Address - City:SAINT FRANCIS
Practice Address - State:MN
Practice Address - Zip Code:55070-9802
Practice Address - Country:US
Practice Address - Phone:651-343-3670
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-04
Last Update Date:2018-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1093306101YA0400X, 261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use DisorderGroup - Single Specialty