Provider Demographics
NPI:1780009357
Name:AMAZING GRACE COUNSELING LLC
Entity type:Organization
Organization Name:AMAZING GRACE COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:YVONNE
Authorized Official - Middle Name:NWINEMU
Authorized Official - Last Name:NDIFOR-MCNEIL
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:804-687-2097
Mailing Address - Street 1:6361 SPRINGCREST LN
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23231-5326
Mailing Address - Country:US
Mailing Address - Phone:804-269-3878
Mailing Address - Fax:804-269-3885
Practice Address - Street 1:6001 LAKESIDE AVE STE 30
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23228-5749
Practice Address - Country:US
Practice Address - Phone:804-269-3837
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-19
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1896-03-001261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health