Provider Demographics
NPI:1538393434
Name:GRACE, VANESSA RENEE (LICSW)
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:RENEE
Last Name:GRACE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7609 NE VANCOUVER MALL DR
Mailing Address - Street 2:H60
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-6751
Mailing Address - Country:US
Mailing Address - Phone:509-230-7047
Mailing Address - Fax:
Practice Address - Street 1:16701 SE MCGILLIVRAY BLVD
Practice Address - Street 2:SUITE 215
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-3485
Practice Address - Country:US
Practice Address - Phone:360-818-4376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-06
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
WALW603388211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker