Healthcare Provider Details

I. General information

NPI: 1558856039
Provider Name (Legal Business Name): KARA GRACE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2018
Last Update Date: 06/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2201 N BUFFALO DR APT 2012
LAS VEGAS NV
89128-0280
US

IV. Provider business mailing address

2201 N BUFFALO DR APT 2012
LAS VEGAS NV
89128-0280
US

V. Phone/Fax

Practice location:
  • Phone: 310-953-6423
  • Fax:
Mailing address:
  • Phone: 310-953-6423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225XM0800X
TaxonomyMental Health Occupational Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: