Provider Demographics
NPI:1679781991
Name:GRACEN, LINDA (MFT)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:GRACEN
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N MAIN ST
Mailing Address - Street 2:F
Mailing Address - City:FORT BRAGG
Mailing Address - State:CA
Mailing Address - Zip Code:95437-3622
Mailing Address - Country:US
Mailing Address - Phone:707-964-4819
Mailing Address - Fax:
Practice Address - Street 1:250 N MAIN ST
Practice Address - Street 2:F
Practice Address - City:FORT BRAGG
Practice Address - State:CA
Practice Address - Zip Code:95437-3622
Practice Address - Country:US
Practice Address - Phone:707-964-4189
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2010-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC44144106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1679781991OtherNPI