Provider Demographics
NPI:1669066767
Name:LAGRACE WELLNESS CENTER, INC
Entity type:Organization
Organization Name:LAGRACE WELLNESS CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:LAGRACE
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:407-414-4353
Mailing Address - Street 1:634 1ST ST S
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880-3603
Mailing Address - Country:US
Mailing Address - Phone:863-232-7610
Mailing Address - Fax:
Practice Address - Street 1:634 1ST ST S
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-3603
Practice Address - Country:US
Practice Address - Phone:863-232-7610
Practice Address - Fax:863-774-0981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-01
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty