Provider Demographics
NPI:1578012613
Name:EMMA, GRACE
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:EMMA
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 1:812 TULE ST
Mailing Address - Street 2:
Mailing Address - City:MONTOURSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17754-1138
Mailing Address - Country:US
Mailing Address - Phone:570-244-5571
Mailing Address - Fax:
Practice Address - Street 1:812 TULE ST
Practice Address - Street 2:
Practice Address - City:MONTOURSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17754-1138
Practice Address - Country:US
Practice Address - Phone:570-244-5571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-30
Last Update Date:2016-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist