Provider Demographics
NPI:1073057410
Name:GRACE, RANDALL
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:
Last Name:GRACE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 INDEPENDENCE DR
Mailing Address - Street 2:
Mailing Address - City:HAZARD
Mailing Address - State:KY
Mailing Address - Zip Code:41701-9443
Mailing Address - Country:US
Mailing Address - Phone:606-487-1646
Mailing Address - Fax:606-487-1746
Practice Address - Street 1:48 INDEPENDENCE DR
Practice Address - Street 2:
Practice Address - City:HAZARD
Practice Address - State:KY
Practice Address - Zip Code:41701-9443
Practice Address - Country:US
Practice Address - Phone:606-487-1646
Practice Address - Fax:606-487-1746
Is Sole Proprietor?:No
Enumeration Date:2016-12-05
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)