Provider Demographics
NPI:1164876785
Name:GRACE, REBECCA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:
Last Name:GRACE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 871
Mailing Address - Street 2:
Mailing Address - City:SUN VALLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83353-0871
Mailing Address - Country:US
Mailing Address - Phone:760-310-9085
Mailing Address - Fax:
Practice Address - Street 1:200 RIVER ST EAST
Practice Address - Street 2:
Practice Address - City:KETCHUM
Practice Address - State:ID
Practice Address - Zip Code:83340
Practice Address - Country:US
Practice Address - Phone:760-310-9085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-20
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY10109103TC0700X
CAMFT22933106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist