Provider Demographics
NPI:1811733074
Name:THE GRACE SPACE, LLC.
Entity type:Organization
Organization Name:THE GRACE SPACE, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DENITRA
Authorized Official - Middle Name:
Authorized Official - Last Name:BEASLEY
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:318-417-9046
Mailing Address - Street 1:6308 ESTATES DR
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:LA
Mailing Address - Zip Code:71220-9748
Mailing Address - Country:US
Mailing Address - Phone:318-417-9046
Mailing Address - Fax:
Practice Address - Street 1:6308 ESTATES DR
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:LA
Practice Address - Zip Code:71220-9748
Practice Address - Country:US
Practice Address - Phone:318-417-9046
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-06
Last Update Date:2024-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA3400511Medicaid