Provider Demographics
NPI:1538847504
Name:UPTON, GRACIE A
Entity type:Individual
Prefix:
First Name:GRACIE
Middle Name:A
Last Name:UPTON
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 1:1215 INDEPENDENCE BLVD BLDG 6
Mailing Address - Street 2:
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791-7390
Mailing Address - Country:US
Mailing Address - Phone:225-286-1547
Mailing Address - Fax:
Practice Address - Street 1:1215 INDEPENDENCE BLVD BLDG 6
Practice Address - Street 2:
Practice Address - City:ZACHARY
Practice Address - State:LA
Practice Address - Zip Code:70791-7390
Practice Address - Country:US
Practice Address - Phone:225-286-1547
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-10
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician