Basic Information
| Provider Information | |||||||||
| NPI: | 1588898779 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INFINITE GRACE ACADEMY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | INFINATE GRACE ACADEMY | ||||||||
| OtherOrganizationType: | 4 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2108 LEWIS TURNER BLVD. | ||||||||
| Address2: | |||||||||
| City: | FT. WALTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508642273 | ||||||||
| FaxNumber: | 8508626270 | ||||||||
| Practice Location | |||||||||
| Address1: | 2108 LEWIS TURNER BLVD. | ||||||||
| Address2: | |||||||||
| City: | FT. WALTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508642273 | ||||||||
| FaxNumber: | 8508626270 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2009 | ||||||||
| LastUpdateDate: | 05/13/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LAMBERT | ||||||||
| AuthorizedOfficialFirstName: | LYNN | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | CO-OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8508642273 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialCredential: | MS CCC SLP | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.