Healthcare Provider Details

I. General information

NPI: 1194855064
Provider Name (Legal Business Name): GRACE LE PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1180 W BALL RD UNIT 8863
ANAHEIM CA
92812-1635
US

IV. Provider business mailing address

PO BOX 8863
ANAHEIM CA
92812-0863
US

V. Phone/Fax

Practice location:
  • Phone: 714-312-7450
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY28187
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: