MEDICARE: MS. ANGELA ELEANOR GRACE MSW, LCSW

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	1041C0700X	Clinical Social Worker	149017866	IL
2	1041C0700X	Clinical Social Worker	2014007196	MO

General Provider Information

NPI Number	:	1821001322
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ANGELA ELEANOR GRACE MSW, LCSW

Provider Business Mailing Address
First Line	:	1448 SAINT LOUIS ST
Second Line	:
City	:	FLORISSANT
State	:	MO
Zip	:	63033-3444
Country	:	US
Telephone Number	:	314-374-6278
Fax Number	:	314-667-3398

Provider Business Practice Location Address
First Line	:	1448 SAINT LOUIS ST
Second Line	:
City	:	FLORISSANT
State	:	MO
Zip	:	63033-3444
Country	:	US
Telephone Number	:	314-374-6278
Fax Number	:	314-667-3398

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/14/2006
Last Update Date	:	10/26/2022

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