Provider Demographics
NPI:1760200240
Name:TEO, GRACE
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:TEO
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 1:286 EL BOSQUE AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95134-1605
Mailing Address - Country:US
Mailing Address - Phone:510-862-2219
Mailing Address - Fax:
Practice Address - Street 1:505 SEAPORT CT STE 103
Practice Address - Street 2:
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94063-5574
Practice Address - Country:US
Practice Address - Phone:650-260-4655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-02
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41828225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty