Basic Information
| Provider Information | |||||||||
| NPI: | 1558485870 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRACE | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | JON | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA, LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GRACE | ||||||||
| OtherFirstName: | RICHARD | ||||||||
| OtherMiddleName: | JON | ||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MA, LPC | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3225 INDEPENDENCE RD | ||||||||
| Address2: | |||||||||
| City: | CANON CITY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812129380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7192752351 | ||||||||
| FaxNumber: | 7192699386 | ||||||||
| Practice Location | |||||||||
| Address1: | 3225 INDEPENDENCE RD | ||||||||
| Address2: | |||||||||
| City: | CANON CITY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812129380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7192752351 | ||||||||
| FaxNumber: | 7192699386 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2007 | ||||||||
| LastUpdateDate: | 12/10/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | LPC.0005595 | CO | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.