Provider Demographics
NPI:1831938596
Name:ROODBAR, GRACE R (LCSW, PPSC)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:R
Last Name:ROODBAR
Suffix:
Gender:F
Credentials:LCSW, PPSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95820-1527
Mailing Address - Country:US
Mailing Address - Phone:269-266-3138
Mailing Address - Fax:
Practice Address - Street 1:4600 BROADWAY
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95820-1527
Practice Address - Country:US
Practice Address - Phone:269-266-3138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-22
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1134031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical