Healthcare Provider Details

I. General information

NPI: 1215229042
Provider Name (Legal Business Name): GRACE KERR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2011
Last Update Date: 05/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9413 FLATLANDS AVE
BROOKLYN NY
11236-3726
US

IV. Provider business mailing address

1670 E 17TH ST
BROOKLYN NY
11229-1281
US

V. Phone/Fax

Practice location:
  • Phone: 718-272-1600
  • Fax: 718-272-1669
Mailing address:
  • Phone: 718-375-1200
  • Fax: 718-382-3358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number071507-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: