=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679033583
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GAGE RAYMOND GRACE
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/25/2019
-----------------------------------------------------
Last Update Date | 11/14/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3501 SHEPPARD ACCESS RD
-----------------------------------------------------
City | WICHITA FALLS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76306-4235
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 940-782-8397
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4084 REGENT DR
-----------------------------------------------------
City | WICHITA FALLS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76308-1508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 940-228-5297
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------