Provider Demographics
NPI:1760686307
Name:GRACE, KIMBERLY
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:
Last Name:GRACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:948 11TH ST
Mailing Address - Street 2:SUITE 20
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95354-2308
Mailing Address - Country:US
Mailing Address - Phone:209-579-1151
Mailing Address - Fax:209-579-9605
Practice Address - Street 1:948 11TH ST
Practice Address - Street 2:SUITE 20
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-2308
Practice Address - Country:US
Practice Address - Phone:209-579-1151
Practice Address - Fax:209-579-9605
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA101YA040OXOtherADDICTION COUNSELOR