Provider Demographics
NPI:1356004873
Name:VANDAHLEN, GRACE
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:VANDAHLEN
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 1:103 MACDOUGAL ST APT 14
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10012-1216
Mailing Address - Country:US
Mailing Address - Phone:240-543-7006
Mailing Address - Fax:
Practice Address - Street 1:103 MACDOUGAL ST APT 14
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10012-1216
Practice Address - Country:US
Practice Address - Phone:240-543-7006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-21
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP112248101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health