Healthcare Provider Details

I. General information

NPI: 1427936046
Provider Name (Legal Business Name): BONNIE GRACE HEAD ED.S, NCSP, PPS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2025
Last Update Date: 08/22/2025
Certification Date: 08/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 N MAIN ST
SOQUEL CA
95073-2212
US

IV. Provider business mailing address

620 MONTEREY AVE
CAPITOLA CA
95010-3618
US

V. Phone/Fax

Practice location:
  • Phone: 831-464-5650
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number230149580
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: