Healthcare Provider Details

I. General information

NPI: 1053001198
Provider Name (Legal Business Name): GRACE ELIZABETH BOLEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2023
Last Update Date: 10/10/2023
Certification Date: 10/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2828 FORD ST
OAKLAND CA
94601-2114
US

IV. Provider business mailing address

2828 FORD ST
OAKLAND CA
94601-2114
US

V. Phone/Fax

Practice location:
  • Phone: 510-268-3770
  • Fax:
Mailing address:
  • Phone: 510-268-3770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number14728
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number141906
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: