Provider Demographics
NPI:1659564607
Name:GRACE, GERARD A
Entity Type:Individual
Prefix:DR
First Name:GERARD
Middle Name:A
Last Name:GRACE
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:GERRY
Other - Middle Name:A
Other - Last Name:GRACE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD, MDIV
Mailing Address - Street 1:2127 MOUNTAIN MIST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-4913
Mailing Address - Country:US
Mailing Address - Phone:210-205-6187
Mailing Address - Fax:830-980-3338
Practice Address - Street 1:1602 THOUSAND OAKS DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232-2338
Practice Address - Country:US
Practice Address - Phone:210-205-6187
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-23
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15411101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional