Provider Demographics
NPI:1144681198
Name:GRACE, KATIE
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:GRACE
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 1:1340 NW WALL ST
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97703-1985
Mailing Address - Country:US
Mailing Address - Phone:541-408-2955
Mailing Address - Fax:
Practice Address - Street 1:409 COUNTY ROAD 4791
Practice Address - Street 2:
Practice Address - City:BOYD
Practice Address - State:TX
Practice Address - Zip Code:76023-5400
Practice Address - Country:US
Practice Address - Phone:757-339-2652
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-17
Last Update Date:2024-08-22
Deactivation Date:2023-12-14
Deactivation Code:
Reactivation Date:2024-08-19
Provider Licenses
StateLicense IDTaxonomies
175T00000X
TX693221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No175T00000XOther Service ProvidersPeer Specialist