Organization
GRACE GARDENS, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
ANITA F MCCORMACK MSW, LCSW (ORGANIZER)
(314) 650-3281
Entity
Organization
Contact information
Practice address
412 N FRANKLIN ST, STE 205, CUBA, MO 65453-1719
(314) 650-3281
(573) 885-1600
Mailing address
130 REDWOOD LN, BOURBON, MO 65441-7118
(314) 650-3281
(573) 885-1600
Taxonomy
Speciality
Code
Description
License number
State
261QM0850X
Adult Mental Health Clinic/Center
2005031753
MO
261QM0855X
Adolescent and Children Mental Health Clinic/Center
Primary
2005031753
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1891830477
INDIVIDUAL NPI
MO
Enumeration date
03/11/2011
Last updated
03/11/2011
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