Organization
GRACE CLINICAL COUNSELING CENTRE, INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
WILDINE BURGESS (EXECUTIVE ADMINISTRATOR)
(240) 350-2863
Entity
Organization
Contact information
Practice address
5062 N 19TH AVE STE 100, PHOENIX, AZ 85015-3225
(602) 855-0002
Mailing address
5062 N 19TH AVE STE 100, PHOENIX, AZ 85015-3225
(602) 855-0002
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
—
—
171M00000X
Case Manager/Care Coordinator
—
—
2084A0401X
Addiction Medicine (Psychiatry & Neurology) Physician
—
—
261QM0850X
Adult Mental Health Clinic/Center
Primary
—
—
261QP2300X
Primary Care Clinic/Center
—
—
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
—
—
363LP2300X
Primary Care Nurse Practitioner
—
—
Other
Enumeration date
12/03/2021
Last updated
12/03/2021
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