Healthcare Provider Details

I. General information

NPI: 1366165987
Provider Name (Legal Business Name): LAURA MARISE GRACE MA, CAGS, NCSP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2022
Last Update Date: 03/08/2023
Certification Date: 03/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

144 SOUTH ST
CONCORD NH
03301-2705
US

IV. Provider business mailing address

144 SOUTH ST
CONCORD NH
03301-2705
US

V. Phone/Fax

Practice location:
  • Phone: 603-230-1599
  • Fax:
Mailing address:
  • Phone: 603-230-1599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number110761
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: