Provider Demographics
NPI:1174853584
Name:GENGOUX, GRACE WERNER (PHD, BCBA-D)
Entity Type:Individual
Prefix:DR
First Name:GRACE
Middle Name:WERNER
Last Name:GENGOUX
Suffix:
Gender:F
Credentials:PHD, BCBA-D
Other - Prefix:
Other - First Name:GRACE
Other - Middle Name:ALLEN
Other - Last Name:WERNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10687 WILKINS AVE
Mailing Address - Street 2:#1
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-5832
Mailing Address - Country:US
Mailing Address - Phone:805-451-5581
Mailing Address - Fax:
Practice Address - Street 1:725 WELCH RD
Practice Address - Street 2:MC: 5500
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94304-1601
Practice Address - Country:US
Practice Address - Phone:650-723-5511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-07
Last Update Date:2010-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY23235103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent