Provider Demographics
NPI:1851061071
Name:GRACE PSYCHIATRIC CLINIC
Entity Type:Organization
Organization Name:GRACE PSYCHIATRIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:OLUSEUN
Authorized Official - Middle Name:ADESOLA
Authorized Official - Last Name:AKINTUNLAJI,
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:551-388-6392
Mailing Address - Street 1:720 SNOWY ORCHID LN
Mailing Address - Street 2:
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-6691
Mailing Address - Country:US
Mailing Address - Phone:551-388-6392
Mailing Address - Fax:855-461-3377
Practice Address - Street 1:5282 MEDICAL DR STE 605
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-6114
Practice Address - Country:US
Practice Address - Phone:551-388-6392
Practice Address - Fax:210-444-2171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-18
Last Update Date:2021-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No251B00000XAgenciesCase Management