Provider Demographics
NPI:1609580968
Name:ADCOCK, GRACE ELIZABETH
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:ELIZABETH
Last Name:ADCOCK
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 1:10732 S MALL DR APT 725
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-4819
Mailing Address - Country:US
Mailing Address - Phone:225-229-4734
Mailing Address - Fax:
Practice Address - Street 1:10732 S MALL DR APT 725
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-4819
Practice Address - Country:US
Practice Address - Phone:225-229-4734
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-11
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA103K00000X, 106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAXUP200605175OtherBLUE CROSS BLUE SHIELD
LA200605175OtherBLUE CROSS