Provider Demographics
NPI:1447295654
Name:GRACE CHRISTIAN COUNSELING CENTER
Entity type:Organization
Organization Name:GRACE CHRISTIAN COUNSELING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:FRAZIER
Authorized Official - Suffix:
Authorized Official - Credentials:LPC,MCP,NCC
Authorized Official - Phone:601-636-5703
Mailing Address - Street 1:1414 CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-3218
Mailing Address - Country:US
Mailing Address - Phone:601-636-5703
Mailing Address - Fax:601-636-5739
Practice Address - Street 1:1414 CHERRY ST
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-3218
Practice Address - Country:US
Practice Address - Phone:601-636-5703
Practice Address - Fax:601-636-5739
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS779101YP2500X
MS1046101YP2500X
MSC5390104100000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty