Provider Demographics
NPI:1477050839
Name:GOVER, GRACE
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:GOVER
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 1:130 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03103-5381
Mailing Address - Country:US
Mailing Address - Phone:401-559-1660
Mailing Address - Fax:
Practice Address - Street 1:130 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03103-5381
Practice Address - Country:US
Practice Address - Phone:401-559-1660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-11
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0-18--8587106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst