Healthcare Provider Details

I. General information

NPI: 1396119038
Provider Name (Legal Business Name): GRACE KAREN GAINES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2015
Last Update Date: 07/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1529 E PALMDALE BLVD
PALMDALE CA
93550-2034
US

IV. Provider business mailing address

1529 E PALMDALE BLVD STE 210
PALMDALE CA
93550-2029
US

V. Phone/Fax

Practice location:
  • Phone: 661-272-9996
  • Fax: 661-272-0438
Mailing address:
  • Phone: 661-272-9996
  • Fax: 661-272-0438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberAMF108852
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: