Provider Demographics
NPI:1255005914
Name:MCCLENTIC, GRACE
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:MCCLENTIC
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 1:815 SANDY LN APT 97
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02889-8051
Mailing Address - Country:US
Mailing Address - Phone:339-987-2195
Mailing Address - Fax:
Practice Address - Street 1:245 WATERMAN ST STE 504A
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-5215
Practice Address - Country:US
Practice Address - Phone:339-987-2195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-05
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMHC01146101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health