Provider Demographics
NPI:1932830726
Name:OKUGBERE, GRACE
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:OKUGBERE
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 1:409 MANTLE CT
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79706-2915
Mailing Address - Country:US
Mailing Address - Phone:432-254-8155
Mailing Address - Fax:
Practice Address - Street 1:409 MANTLE CT
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79706-2915
Practice Address - Country:US
Practice Address - Phone:432-254-8155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-22
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX77955101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty