Provider Demographics
NPI:1760981732
Name:WAKIM, GRACE (PSYD)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:WAKIM
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1160 N DUTTON AVE
Mailing Address - Street 2:STE 230
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-4658
Mailing Address - Country:US
Mailing Address - Phone:707-303-3243
Mailing Address - Fax:
Practice Address - Street 1:3900 LAKEVILLE HWY
Practice Address - Street 2:MOB 2
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-5968
Practice Address - Country:US
Practice Address - Phone:707-765-3565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-06
Last Update Date:2019-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29666103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist