Healthcare Provider Details

I. General information

NPI: 1851208276
Provider Name (Legal Business Name): MS. GRACE SHORTLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13697 ALTA LOMA LN
JAMUL CA
91935-1604
US

IV. Provider business mailing address

13697 ALTA LOMA LN
JAMUL CA
91935-1604
US

V. Phone/Fax

Practice location:
  • Phone: 619-625-0333
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberY7784619
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: