Provider Demographics
NPI:1871158733
Name:GRACE & GROWTH PSYCHOLOGY SERVICES, PLLC
Entity type:Organization
Organization Name:GRACE & GROWTH PSYCHOLOGY SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:M
Authorized Official - Last Name:WAHL
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:701-415-8271
Mailing Address - Street 1:2055 XAVIER ST APT 217
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-1413
Mailing Address - Country:US
Mailing Address - Phone:701-415-8271
Mailing Address - Fax:
Practice Address - Street 1:4719 SHELBURNE ST STE 11
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-5677
Practice Address - Country:US
Practice Address - Phone:701-415-8271
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-07
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)