Provider Demographics
NPI:1255387973
Name:STROUD, GRACE R (MA)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:R
Last Name:STROUD
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 MILLS ST
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27608-1833
Mailing Address - Country:US
Mailing Address - Phone:919-818-3689
Mailing Address - Fax:
Practice Address - Street 1:3948 BROWNING PL
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-6512
Practice Address - Country:US
Practice Address - Phone:919-783-6776
Practice Address - Fax:919-783-6776
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-25
Last Update Date:2018-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2003103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC046HVOtherBCBS
NC6107266Medicaid