Provider Demographics
NPI:1740667732
Name:DAVID, GRACE
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:DAVID
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 1:1122 RIVERBOAT CT
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21409-5439
Mailing Address - Country:US
Mailing Address - Phone:410-271-9557
Mailing Address - Fax:
Practice Address - Street 1:700 MELVIN AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-1514
Practice Address - Country:US
Practice Address - Phone:410-280-9444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-29
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP5066101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional