Provider Demographics
NPI:1275081341
Name:GRACE, THOMAS
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:GRACE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:814 ELMWOOD AVE
Mailing Address - Street 2:APT 2
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14222-1473
Mailing Address - Country:US
Mailing Address - Phone:716-783-3100
Mailing Address - Fax:716-995-3207
Practice Address - Street 1:10 SYMPHONY CIR
Practice Address - Street 2:APT 2
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14201-1363
Practice Address - Country:US
Practice Address - Phone:716-783-3100
Practice Address - Fax:716-995-3207
Is Sole Proprietor?:No
Enumeration Date:2016-09-16
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY098554-1104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker