Healthcare Provider Details

I. General information

NPI: 1003213976
Provider Name (Legal Business Name): AMY GRACE LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2014
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 EL CAMINO REAL STE 155
BURLINGAME CA
94010-3231
US

IV. Provider business mailing address

204 E WOODLANDER DR
EAGLE ID
83616-6322
US

V. Phone/Fax

Practice location:
  • Phone: 650-342-6506
  • Fax:
Mailing address:
  • Phone: 650-218-2222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number37008
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: