Provider Demographics
NPI:1750709549
Name:AMAZING GRACE CHRISTIAN SERVICES
Entity type:Organization
Organization Name:AMAZING GRACE CHRISTIAN SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:D
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:301-809-6310
Mailing Address - Street 1:11205 LAKE VICTORIA LN
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20720-4262
Mailing Address - Country:US
Mailing Address - Phone:301-809-6310
Mailing Address - Fax:
Practice Address - Street 1:11205 LAKE VICTORIA LN
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20720-4262
Practice Address - Country:US
Practice Address - Phone:301-809-6310
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-31
Last Update Date:2014-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCL73048101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Single Specialty