Healthcare Provider Details

I. General information

NPI: 1245536689
Provider Name (Legal Business Name): KECK & GRACE, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2011
Last Update Date: 02/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 DOUGLAS AVE SUITE 3040
ALTAMONTE SPRINGS FL
32714-2061
US

IV. Provider business mailing address

1110 DOUGLAS AVE SUITE 3040
ALTAMONTE SPRINGS FL
32714-2061
US

V. Phone/Fax

Practice location:
  • Phone: 407-644-2000
  • Fax: 407-644-3484
Mailing address:
  • Phone: 407-644-2000
  • Fax: 407-644-3484

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY4007
License Number StateFL

VIII. Authorized Official

Name: MS. GILDA GRACE
Title or Position: TREASURER
Credential: LMHC
Phone: 407-644-2000