Provider Demographics
NPI:1649961905
Name:SILIEZAR, GRACE
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:SILIEZAR
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 1:310 HARBOR BLVD BLDG E
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94002-4018
Mailing Address - Country:US
Mailing Address - Phone:650-802-6431
Mailing Address - Fax:
Practice Address - Street 1:310 HARBOR BLVD BLDG E
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:CA
Practice Address - Zip Code:94002-4018
Practice Address - Country:US
Practice Address - Phone:650-802-6431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-17
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 172V00000X, 101YM0800X, 146D00000X, 171M00000X, 175T00000X, 172V00000X
CAMPSS-ECBIZW175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Yes175T00000XOther Service ProvidersPeer Specialist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant