Provider Demographics
NPI:1114028800
Name:GRACE, GLENN D (PHD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:D
Last Name:GRACE
Suffix:
Gender:M
Credentials:PHD
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Mailing Address - Street 1:1601 SW ARCHER RD
Mailing Address - Street 2:PSYCHOLOGY SERVICE (116B) VA MEDICAL CENTER
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-1197
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1601 SW ARCHER RD
Practice Address - Street 2:PSYCHOLOGY SERVICE (116B) VA MEDICAL CENTER
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-1197
Practice Address - Country:US
Practice Address - Phone:352-376-1611
Practice Address - Fax:352-379-4026
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPY4606103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist