Provider Demographics
NPI:1245914860
Name:SONG, GRACE KANG
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:KANG
Last Name:SONG
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 1:1822 RONIE WAY
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95124-3630
Mailing Address - Country:US
Mailing Address - Phone:669-262-9648
Mailing Address - Fax:
Practice Address - Street 1:505 SAN MARIN DR STE 100B
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94945-1309
Practice Address - Country:US
Practice Address - Phone:336-645-6733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst