Healthcare Provider Details

I. General information

NPI: 1174853584
Provider Name (Legal Business Name): GRACE GENGOUX PH.D., BCBA-D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GRACE ALLEN WERNER

II. Dates (important events)

Enumeration Date: 01/07/2010
Last Update Date: 04/29/2024
Certification Date: 04/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 WELCH RD MC: 5500
PALO ALTO CA
94304-1601
US

IV. Provider business mailing address

725 WELCH RD
PALO ALTO CA
94304-1601
US

V. Phone/Fax

Practice location:
  • Phone: 650-723-5511
  • Fax:
Mailing address:
  • Phone: 650-497-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPSY23235
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: