Basic Information
| Provider Information | |||||||||
| NPI: | 1558727370 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRACE | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 90309 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972900309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183397497 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5415 SE 89TH AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972664754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033355975 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2016 | ||||||||
| LastUpdateDate: | 02/02/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | T1439 | OR | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.