Provider Demographics
NPI:1942370838
Name:MUCCI, GRACE ANNE (PHD, MS, ABPDN)
Entity Type:Individual
Prefix:DR
First Name:GRACE
Middle Name:ANNE
Last Name:MUCCI
Suffix:
Gender:F
Credentials:PHD, MS, ABPDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3086
Mailing Address - Street 2:
Mailing Address - City:SEAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90740-2086
Mailing Address - Country:US
Mailing Address - Phone:949-478-4503
Mailing Address - Fax:562-856-6004
Practice Address - Street 1:200 NEWPORT CENTER DR STE 300
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7504
Practice Address - Country:US
Practice Address - Phone:949-478-4503
Practice Address - Fax:562-856-6004
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY15334103TC0700X, 103G00000X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP15334Medicare ID - Type Unspecified
CAP42900Medicare UPIN