Basic Information
| Provider Information | |||||||||
| NPI: | 1275081341 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRACE | ||||||||
| FirstName: | THOMAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 814 ELMWOOD AVE | ||||||||
| Address2: | APT 2 | ||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142221473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7167833100 | ||||||||
| FaxNumber: | 7169953207 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 SYMPHONY CIR | ||||||||
| Address2: | APT 2 | ||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142011363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7167833100 | ||||||||
| FaxNumber: | 7169953207 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2016 | ||||||||
| LastUpdateDate: | 09/16/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 098554-1 | NY | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 098554-1 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.