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NPI Code Detail

MEDICARE: AMANDA GRACE

MEDICARE: AMANDA GRACE
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101YM0800XMental Health Counselor
2225XP0200XPediatric Occupational TherapistOT5383CA
3225X00000XOccupational TherapistOT5383CA

General Provider Information

NPI Number : 1033326582
Entity Type Code : Individual
Provider Name (Legal Business Name) : AMANDA GRACE
Provider Business Mailing Address
First Line : 340 TESCONI CIR STE C
Second Line :
City : SANTA ROSA
State : CA
Zip : 95401-4676
Country : US
Telephone Number : 707-546-9160
Fax Number :
Provider Business Practice Location Address
First Line : 340 TESCONI CIR STE C
Second Line :
City : SANTA ROSA
State : CA
Zip : 95401-4676
Country : US
Telephone Number : 707-546-9160
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/16/2007
Last Update Date : 10/24/2012

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Directions to “ AMANDA GRACE ” Practice Location

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