Provider Demographics
NPI:1992041081
Name:IRVINE, GRACE MAE (MFT INTERN #IMF76936)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:MAE
Last Name:IRVINE
Suffix:
Gender:F
Credentials:MFT INTERN #IMF76936
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5030 EL CAMINO AVE
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-4650
Mailing Address - Country:US
Mailing Address - Phone:916-949-8107
Mailing Address - Fax:
Practice Address - Street 1:5030 EL CAMINO AVE
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-4650
Practice Address - Country:US
Practice Address - Phone:916-949-8107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-18
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF76936106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist