Provider Demographics
NPI:1649904863
Name:ERWIN, GRACIE JANELLE
Entity type:Individual
Prefix:
First Name:GRACIE
Middle Name:JANELLE
Last Name:ERWIN
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 1:3099 KIRKLEVINGTON DR APT 47
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40517-2471
Mailing Address - Country:US
Mailing Address - Phone:951-285-8449
Mailing Address - Fax:
Practice Address - Street 1:1035 STRADER DR STE 150
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40505-4090
Practice Address - Country:US
Practice Address - Phone:951-285-8449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-13
Last Update Date:2023-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician