Provider Demographics
NPI:1851843940
Name:GRACE BEHAVIORAL SUPPORT SERVICES FL
Entity Type:Organization
Organization Name:GRACE BEHAVIORAL SUPPORT SERVICES FL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CHANTALE
Authorized Official - Middle Name:
Authorized Official - Last Name:MILORD-FERGUSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-508-4148
Mailing Address - Street 1:780 FISHERMAN ST STE 250
Mailing Address - Street 2:
Mailing Address - City:OPA LOCKA
Mailing Address - State:FL
Mailing Address - Zip Code:33054-3807
Mailing Address - Country:US
Mailing Address - Phone:305-681-2500
Mailing Address - Fax:305-681-2525
Practice Address - Street 1:780 FISHERMAN ST STE 210
Practice Address - Street 2:
Practice Address - City:OPA LOCKA
Practice Address - State:FL
Practice Address - Zip Code:33054-3807
Practice Address - Country:US
Practice Address - Phone:305-681-2500
Practice Address - Fax:305-681-2525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-25
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Multi-Specialty
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchoolGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamilyGroup - Multi-Specialty
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty