Provider Demographics
NPI:1245483973
Name:KIDS OF GRACE, INC.
Entity type:Organization
Organization Name:KIDS OF GRACE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANTOINETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODEN
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LPC, NCC
Authorized Official - Phone:404-604-4226
Mailing Address - Street 1:PO BOX 6777
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30154-0030
Mailing Address - Country:US
Mailing Address - Phone:404-604-4226
Mailing Address - Fax:888-242-0387
Practice Address - Street 1:5262 INVERNESS CT
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-6748
Practice Address - Country:US
Practice Address - Phone:404-604-4226
Practice Address - Fax:888-242-0387
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-28
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC005074251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health