Provider Demographics
NPI:1578398707
Name:MENTALGRACE LLC
Entity type:Organization
Organization Name:MENTALGRACE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATRIC NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:GRACE
Authorized Official - Suffix:
Authorized Official - Credentials:MSN-ED, APRN, PMHNP
Authorized Official - Phone:732-614-9321
Mailing Address - Street 1:15656 RANDOLPH PL
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80239-7024
Mailing Address - Country:US
Mailing Address - Phone:732-614-9321
Mailing Address - Fax:
Practice Address - Street 1:15656 RANDOLPH PL
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80239-7024
Practice Address - Country:US
Practice Address - Phone:732-614-9321
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-06
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty