Provider Demographics
NPI:1396376349
Name:GRACE, CAROLYN (PLPC)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:GRACE
Suffix:
Gender:F
Credentials:PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4149 PENNSYLVANIA AVE STE 205
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64111-3034
Mailing Address - Country:US
Mailing Address - Phone:940-816-5316
Mailing Address - Fax:
Practice Address - Street 1:405 NE 90TH TER
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64155-2445
Practice Address - Country:US
Practice Address - Phone:940-613-2989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-29
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019045710101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional