Provider Demographics
NPI:1720311467
Name:GRACE, AARON JOHN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:AARON
Middle Name:JOHN
Last Name:GRACE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 NW BARSTOW ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-3771
Mailing Address - Country:US
Mailing Address - Phone:262-548-6903
Mailing Address - Fax:262-548-3820
Practice Address - Street 1:210 NW BARSTOW ST
Practice Address - Street 2:SUITE 201
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-3771
Practice Address - Country:US
Practice Address - Phone:262-548-6903
Practice Address - Fax:262-548-3820
Is Sole Proprietor?:No
Enumeration Date:2009-09-14
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3049-57103TH0004X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1720311467Medicaid