Provider Demographics
NPI:1942575105
Name:GRACE, REGINALD SR (LPC)
Entity Type:Individual
Prefix:MR
First Name:REGINALD
Middle Name:
Last Name:GRACE
Suffix:SR
Gender:M
Credentials:LPC
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 287
Mailing Address - Street 2:
Mailing Address - City:SAINT GABRIEL
Mailing Address - State:LA
Mailing Address - Zip Code:70776-0287
Mailing Address - Country:US
Mailing Address - Phone:225-642-5104
Mailing Address - Fax:225-642-5107
Practice Address - Street 1:6225 PLANTATION DR.
Practice Address - Street 2:
Practice Address - City:ST. GABRIEL
Practice Address - State:LA
Practice Address - Zip Code:70776
Practice Address - Country:US
Practice Address - Phone:225-642-5104
Practice Address - Fax:225-642-5107
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-20
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA819101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional