Provider Demographics
NPI:1740794858
Name:GRACE, KENNETH ELAM SR
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:ELAM
Last Name:GRACE
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3770 N HIGH ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43214-3525
Mailing Address - Country:US
Mailing Address - Phone:614-294-7117
Mailing Address - Fax:
Practice Address - Street 1:3770 N HIGH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-3525
Practice Address - Country:US
Practice Address - Phone:614-294-7117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-28
Last Update Date:2017-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker