Basic Information
| Provider Information | |||||||||
| NPI: | 1366184129 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRACE | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSW ASW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3626 W AVENUE 42 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900654304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2139098384 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7101 BAIRD AVE | ||||||||
| Address2: | |||||||||
| City: | RESEDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913354150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8183425897 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2022 | ||||||||
| LastUpdateDate: | 04/12/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 97954 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.