Provider Demographics
NPI:1033608104
Name:YANG, GRACE S
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:S
Last Name:YANG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 OLD KINGS HWY
Mailing Address - Street 2:
Mailing Address - City:NEW CANAAN
Mailing Address - State:CT
Mailing Address - Zip Code:06840-6413
Mailing Address - Country:US
Mailing Address - Phone:917-520-4251
Mailing Address - Fax:
Practice Address - Street 1:30 BUXTON FARM RD STE 105
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-1210
Practice Address - Country:US
Practice Address - Phone:203-674-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-04
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CT1262103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110026265EMedicaid