Healthcare Provider Details

I. General information

NPI: 1144952094
Provider Name (Legal Business Name): BRIAN JOHN GRACE PMHNP-BC, MBA, RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2022
Last Update Date: 06/29/2022
Certification Date: 06/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 CABOT RD STE 201
MEDFORD MA
02155-5173
US

IV. Provider business mailing address

10 CABOT RD STE 201
MEDFORD MA
02155-5173
US

V. Phone/Fax

Practice location:
  • Phone: 800-915-3211
  • Fax:
Mailing address:
  • Phone: 800-915-3211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2022010797
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: