MEDICARE: MRS. GILDA GRACE LMHC

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
1	101YM0800X	Mental Health Counselor	MH3446	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	Z6108	OTHER	FL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1265437826
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. GILDA GRACE LMHC

Provider Business Mailing Address
First Line	:	1110 DOUGLAS AVE
Second Line	:	STE 3040
City	:	ALTAMONTE SPRINGS
State	:	FL
Zip	:	32714-2060
Country	:	US
Telephone Number	:	407-644-2000
Fax Number	:	407-644-3484

Provider Business Practice Location Address
First Line	:	1110 DOUGLAS AVE
Second Line	:	STE 3040
City	:	ALTAMONTE SPRINGS
State	:	FL
Zip	:	32714-2060
Country	:	US
Telephone Number	:	407-644-2000
Fax Number	:	407-644-3484

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/20/2005
Last Update Date	:	07/08/2007

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