Basic Information
| Provider Information | |||||||||
| NPI: | 1831842244 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLURRED GRACE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1054 HAWTHORNE DR | ||||||||
| Address2: | |||||||||
| City: | MCCOMB | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396489551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012481218 | ||||||||
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| Practice Location | |||||||||
| Address1: | 921 AVENUE G | ||||||||
| Address2: | |||||||||
| City: | KENTWOOD | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704442639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9852290717 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2022 | ||||||||
| LastUpdateDate: | 01/27/2022 | ||||||||
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| AuthorizedOfficialLastName: | WOODS | ||||||||
| AuthorizedOfficialFirstName: | HEATHER | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6012481218 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | NP | ||||||||
| NPICertificationDate: | 01/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.