Provider Demographics
NPI:1023395928
Name:AYANDIBU, GRACE (MD, MS, LPC)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:AYANDIBU
Suffix:
Gender:F
Credentials:MD, MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2637 PLAZA PKWY
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76308-3889
Mailing Address - Country:US
Mailing Address - Phone:940-666-3060
Mailing Address - Fax:
Practice Address - Street 1:2637 PLAZA PKWY
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76308-3889
Practice Address - Country:US
Practice Address - Phone:940-239-9160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-08
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178007242101YM0800X
390200000X
TXT9346207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program