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General NPI Number Information
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NPI Number | 1801914239
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Entity Type | Individual
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Provider Name | LISA GRACE
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Gender | Female
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Dates
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Enumeration Date | 03/26/2007
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Last Update Date | 12/02/2016
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Provider Practice Location Address
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Address Line | 818 CHERRY ST
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City | SANTA ROSA
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State | CA
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Zip | 95404-4207
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Country | US
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Telephone | 707-217-3298
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Fax |
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Provider Business Mailing Address
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Address Line | 3650 KELSEY KNLS APT. 738
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City | SANTA ROSA
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State | CA
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Zip | 95403-0158
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Country | US
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Telephone | 707-217-3298
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 96216
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License Number State | CA
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