Provider Demographics
NPI:1265125579
Name:MALICOAT, GRACIE LAUREN
Entity type:Individual
Prefix:
First Name:GRACIE
Middle Name:LAUREN
Last Name:MALICOAT
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 1:19201 E VALLEY VIEW PKWY STE H
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64055-6913
Mailing Address - Country:US
Mailing Address - Phone:816-474-3995
Mailing Address - Fax:
Practice Address - Street 1:19201 E VALLEY VIEW PKWY STE H
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64055-6913
Practice Address - Country:US
Practice Address - Phone:816-474-3995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-01
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOOSDXPRLTS106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician