Basic Information
| Provider Information | |||||||||
| NPI: | 1851061071 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GRACE PSYCHIATRIC CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 720 SNOWY ORCHID LN | ||||||||
| Address2: | |||||||||
| City: | DESOTO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 751156691 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5513886392 | ||||||||
| FaxNumber: | 8554613377 | ||||||||
| Practice Location | |||||||||
| Address1: | 5282 MEDICAL DR STE 605 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782296114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5513886392 | ||||||||
| FaxNumber: | 2104442171 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2021 | ||||||||
| LastUpdateDate: | 09/18/2021 | ||||||||
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| AuthorizedOfficialLastName: | AKINTUNLAJI, | ||||||||
| AuthorizedOfficialFirstName: | OLUSEUN | ||||||||
| AuthorizedOfficialMiddleName: | ADESOLA | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5513886392 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | NP | ||||||||
| NPICertificationDate: | 09/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional | 2084P0800X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 251B00000X | N | Agencies | Case Management | 363LP0808X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.