Provider Demographics
NPI:1235721143
Name:GUILLORY, GRACE V
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:V
Last Name:GUILLORY
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 1:124 E MIRACLE STRIP PKWY STE 202
Mailing Address - Street 2:
Mailing Address - City:MARY ESTHER
Mailing Address - State:FL
Mailing Address - Zip Code:32569-1990
Mailing Address - Country:US
Mailing Address - Phone:850-744-0118
Mailing Address - Fax:
Practice Address - Street 1:124 E MIRACLE STRIP PKWY STE 202
Practice Address - Street 2:
Practice Address - City:MARY ESTHER
Practice Address - State:FL
Practice Address - Zip Code:32569-1990
Practice Address - Country:US
Practice Address - Phone:850-744-0118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-11
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-21-150187106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician