Provider Demographics
NPI:1265654156
Name:GRACE, JUDITH B (LCPC)
Entity Type:Individual
Prefix:MS
First Name:JUDITH
Middle Name:B
Last Name:GRACE
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:290 NORTHPORT AVE
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915
Mailing Address - Country:US
Mailing Address - Phone:207-338-6243
Mailing Address - Fax:207-338-6243
Practice Address - Street 1:290 NORTHPORT AVE
Practice Address - Street 2:
Practice Address - City:BELFAST
Practice Address - State:ME
Practice Address - Zip Code:04915
Practice Address - Country:US
Practice Address - Phone:207-338-6243
Practice Address - Fax:207-338-6243
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME#668101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME027118OtherANTHEM