Provider Demographics
NPI:1053850065
Name:GRATIA PLENA
Entity type:Organization
Organization Name:GRATIA PLENA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:BUCKLE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:832-532-0129
Mailing Address - Street 1:10707 CORPORATE DR
Mailing Address - Street 2:SUITE 135
Mailing Address - City:STAFFORD
Mailing Address - State:TX
Mailing Address - Zip Code:77477-4095
Mailing Address - Country:US
Mailing Address - Phone:832-532-0129
Mailing Address - Fax:
Practice Address - Street 1:10707 CORPORATE DR
Practice Address - Street 2:SUITE 135
Practice Address - City:STAFFORD
Practice Address - State:TX
Practice Address - Zip Code:77477-4095
Practice Address - Country:US
Practice Address - Phone:832-532-0129
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-23
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)