Provider Demographics
NPI:1639110414
Name:USIGBE, GRACE E
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:E
Last Name:USIGBE
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:PO BOX 71170
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92513-1170
Mailing Address - Country:US
Mailing Address - Phone:951-237-6524
Mailing Address - Fax:
Practice Address - Street 1:4262 LAKEFALL CT
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-3459
Practice Address - Country:US
Practice Address - Phone:951-237-6524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5374550001174400000X
CA113268106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5374550001Medicare ID - Type UnspecifiedPROVIDER NUMBER