Provider Demographics
NPI:1245536689
Name:KECK & GRACE, PA
Entity type:Organization
Organization Name:KECK & GRACE, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:MS
Authorized Official - First Name:GILDA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRACE
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:407-644-2000
Mailing Address - Street 1:1110 DOUGLAS AVE
Mailing Address - Street 2:SUITE 3040
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32714-2061
Mailing Address - Country:US
Mailing Address - Phone:407-644-2000
Mailing Address - Fax:407-644-3484
Practice Address - Street 1:1110 DOUGLAS AVE
Practice Address - Street 2:SUITE 3040
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32714-2061
Practice Address - Country:US
Practice Address - Phone:407-644-2000
Practice Address - Fax:407-644-3484
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-02
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY4007103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty