Provider Demographics
NPI:1356697700
Name:ETCHEVERRY, GRACIANNA (LCSW)
Entity type:Individual
Prefix:
First Name:GRACIANNA
Middle Name:
Last Name:ETCHEVERRY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:GRACE
Other - Middle Name:
Other - Last Name:ETCHEVERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:WASCO STATE PRISON
Mailing Address - Street 2:701 SCOFIELD AVE
Mailing Address - City:WASCO
Mailing Address - State:CA
Mailing Address - Zip Code:93280
Mailing Address - Country:US
Mailing Address - Phone:661-758-8400
Mailing Address - Fax:
Practice Address - Street 1:900 WALT WHITMAN RD
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-2293
Practice Address - Country:US
Practice Address - Phone:516-698-5511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-02
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0895241041C0700X
CALCSW1194461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical