Provider Demographics
NPI:1619547577
Name:DU BOIS, GRACE TINUNGKI
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:TINUNGKI
Last Name:DU BOIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:GRACE
Other - Middle Name:
Other - Last Name:TINUNGKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4160 OCOEE ST N STE 8
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37312-4886
Mailing Address - Country:US
Mailing Address - Phone:888-281-4257
Mailing Address - Fax:
Practice Address - Street 1:4160 OCOEE ST N STE 8
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37312-4886
Practice Address - Country:US
Practice Address - Phone:888-281-4257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-01
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN725614101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool