Provider Demographics
NPI:1750932414
Name:MICKLE, GRACE CATHERINE (LMFT)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:CATHERINE
Last Name:MICKLE
Suffix:
Gender:
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 WILLARD AVE
Mailing Address - Street 2:
Mailing Address - City:BRAWLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92227-3048
Mailing Address - Country:US
Mailing Address - Phone:619-585-7686
Mailing Address - Fax:
Practice Address - Street 1:507 WILLARD AVE
Practice Address - Street 2:
Practice Address - City:BRAWLEY
Practice Address - State:CA
Practice Address - Zip Code:92227-3048
Practice Address - Country:US
Practice Address - Phone:619-585-7686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-24
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0717002396106H00000X
CA153519106H00000X
CA138499106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist