MEDICARE: PRIDE AND GRACE FAMILY COUNSELING, INC.

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1720652654
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIDE AND GRACE FAMILY COUNSELING, INC.

Provider Business Mailing Address
First Line	:	PO BOX 6963
Second Line	:
City	:	SAN MATEO
State	:	CA
Zip	:	94403-6963
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	122 2ND AVE STE 212
Second Line	:
City	:	SAN MATEO
State	:	CA
Zip	:	94401-3836
Country	:	US
Telephone Number	:	650-701-3978
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	PRISCILLA CHENG
Credential	:	LMFT
Telephone Number	:	650-701-3978

Provider Enumeration Date	:	05/15/2021
Last Update Date	:	05/15/2021

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