Provider Demographics
NPI:1881087401
Name:GRACE FAMILY THERAPY, INC
Entity type:Organization
Organization Name:GRACE FAMILY THERAPY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAELINA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODWIN
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC-SLP
Authorized Official - Phone:970-560-0123
Mailing Address - Street 1:42940 N SUBURBAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85140-9899
Mailing Address - Country:US
Mailing Address - Phone:970-560-0123
Mailing Address - Fax:480-816-7588
Practice Address - Street 1:42940 N SUBURBAN AVE
Practice Address - Street 2:
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85140-9899
Practice Address - Country:US
Practice Address - Phone:970-560-0123
Practice Address - Fax:480-816-7588
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care