Provider Demographics
NPI:1649567728
Name:MACDOWELL, GRACE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:GRACE
Middle Name:
Last Name:MACDOWELL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:GRACE
Other - Middle Name:
Other - Last Name:MACDOWELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:1635 OHIO ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-3032
Mailing Address - Country:US
Mailing Address - Phone:315-681-4112
Mailing Address - Fax:315-282-2888
Practice Address - Street 1:11762 S STATE ST STE 160
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-7174
Practice Address - Country:US
Practice Address - Phone:801-654-3229
Practice Address - Fax:801-601-1408
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-08
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9469748-2501103G00000X, 103TC2200X
NY019217103G00000X, 103TC0700X, 103TM1800X
UT946748-2501103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental DisabilitiesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ300059371OtherMEDICARE PTAN