MEDICARE: KECK & GRACE, PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PY4007	FL

General Provider Information

NPI Number	:	1245536689
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KECK & GRACE, PA

Provider Business Mailing Address
First Line	:	1110 DOUGLAS AVE
Second Line	:	SUITE 3040
City	:	ALTAMONTE SPRINGS
State	:	FL
Zip	:	32714-2061
Country	:	US
Telephone Number	:	407-644-2000
Fax Number	:	407-644-3484

Provider Business Practice Location Address
First Line	:	1110 DOUGLAS AVE
Second Line	:	SUITE 3040
City	:	ALTAMONTE SPRINGS
State	:	FL
Zip	:	32714-2061
Country	:	US
Telephone Number	:	407-644-2000
Fax Number	:	407-644-3484

Authorized Official
Title or Position	:	TREASURER
Name	:	MS. GILDA GRACE
Credential	:	LMHC
Telephone Number	:	407-644-2000

Provider Enumeration Date	:	02/02/2011
Last Update Date	:	02/02/2011

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Directions to “KECK & GRACE, PA ” Practice Location

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