Healthcare Provider Details

I. General information

NPI: 1194189639
Provider Name (Legal Business Name): ANTHONY MICHAEL GRACE LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2016
Last Update Date: 08/02/2023
Certification Date: 08/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

959 SE DIVISION ST STE 520
PORTLAND OR
97214-4672
US

IV. Provider business mailing address

PO BOX 90309
PORTLAND OR
97290-0309
US

V. Phone/Fax

Practice location:
  • Phone: 503-549-4714
  • Fax: 503-506-0411
Mailing address:
  • Phone: 503-549-4714
  • Fax: 503-406-2637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3909
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: