Provider Demographics
NPI:1467793760
Name:GRACE, CHARLENE R (MS)
Entity Type:Individual
Prefix:MRS
First Name:CHARLENE
Middle Name:R
Last Name:GRACE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3909 RESERVE DR APT 2726
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32311-8209
Mailing Address - Country:US
Mailing Address - Phone:850-765-5453
Mailing Address - Fax:
Practice Address - Street 1:3909 RESERVE DR APT 2726
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32311-8209
Practice Address - Country:US
Practice Address - Phone:850-765-5453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-12
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health