Provider Demographics
NPI:1720686074
Name:TEMPLE, GRACE MACKENZIE
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:MACKENZIE
Last Name:TEMPLE
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 1:606 W 1720 N APT 206
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-2476
Mailing Address - Country:US
Mailing Address - Phone:847-826-3883
Mailing Address - Fax:
Practice Address - Street 1:606 W 1720 N APT 206
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-2476
Practice Address - Country:US
Practice Address - Phone:847-826-3883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-09
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX40938791106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician