Provider Demographics
NPI:1689176794
Name:GRACE, KRISTIN (LICSW)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:GRACE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 SW HOLDEN ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98126-3505
Mailing Address - Country:US
Mailing Address - Phone:206-933-7035
Mailing Address - Fax:206-933-7297
Practice Address - Street 1:2600 SW HOLDEN ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98126-3505
Practice Address - Country:US
Practice Address - Phone:206-933-7035
Practice Address - Fax:206-933-7297
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-05
Last Update Date:2018-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW00005728104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WALW00005728Medicaid