Basic Information
| Provider Information | |||||||||
| NPI: | 1093352247 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GRACELI LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6624 TIMOTHY LAKE RD | ||||||||
| Address2: | |||||||||
| City: | EAST STROUDSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 183028686 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5163057659 | ||||||||
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| Practice Location | |||||||||
| Address1: | 529 SEVEN BRIDGE RD UNIT 207 | ||||||||
| Address2: | |||||||||
| City: | EAST STROUDSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 183017608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5704313081 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2019 | ||||||||
| LastUpdateDate: | 12/06/2019 | ||||||||
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| AuthorizedOfficialLastName: | CHARLES | ||||||||
| AuthorizedOfficialFirstName: | LOURNA | ||||||||
| AuthorizedOfficialMiddleName: | ANGELIKA | ||||||||
| AuthorizedOfficialTitleorPosition: | THERAPIST/CEO | ||||||||
| AuthorizedOfficialTelephone: | 5163057659 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.