Provider Demographics
NPI:1659146371
Name:WHITE, GRACE KELLY (ASW)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:KELLY
Last Name:WHITE
Suffix:
Gender:F
Credentials:ASW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5833 MORGAN PL UNIT 42
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-4631
Mailing Address - Country:US
Mailing Address - Phone:747-777-0246
Mailing Address - Fax:
Practice Address - Street 1:1414 N CALIFORNIA ST FL 2
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95202-1515
Practice Address - Country:US
Practice Address - Phone:209-468-2385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-22
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW1134071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical