Provider Demographics
NPI:1326507427
Name:IRVING, GRACE ANTOINETTE
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:ANTOINETTE
Last Name:IRVING
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 1:5995 SE COMMUNITY DR
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-6425
Mailing Address - Country:US
Mailing Address - Phone:772-403-4007
Mailing Address - Fax:772-361-6213
Practice Address - Street 1:525 NW LAKE WHITNEY PL STE 102
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-1605
Practice Address - Country:US
Practice Address - Phone:772-337-8164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-18
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty