Healthcare Provider Details

I. General information

NPI: 1235320391
Provider Name (Legal Business Name): TIMOTHY MARTIN GRACE PSYCHOLOGIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2007
Last Update Date: 01/18/2024
Certification Date: 01/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31625 HIGHWAY 101 S
SOLEDAD CA
93960-9529
US

IV. Provider business mailing address

31625 HIGHWAY 101 S
SOLEDAD CA
93960-9529
US

V. Phone/Fax

Practice location:
  • Phone: 831-809-6745
  • Fax:
Mailing address:
  • Phone: 831-809-6745
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY24472
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: