Provider Demographics
NPI:1154984813
Name:MAIER, GRACE KELLY
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:KELLY
Last Name:MAIER
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:PO BOX 9497
Mailing Address - Street 2:
Mailing Address - City:ALTA LOMA
Mailing Address - State:CA
Mailing Address - Zip Code:91701-8470
Mailing Address - Country:US
Mailing Address - Phone:909-961-4760
Mailing Address - Fax:
Practice Address - Street 1:1460 BROADWAY STE 920
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10036-7329
Practice Address - Country:US
Practice Address - Phone:212-235-5043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-18
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002327103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst