Provider Demographics
NPI:1043032030
Name:CORREA, GRACE
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:CORREA
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 1:4117 N PINE ISLAND RD
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33351-6005
Mailing Address - Country:US
Mailing Address - Phone:954-652-8613
Mailing Address - Fax:954-530-4292
Practice Address - Street 1:4117 N PINE ISLAND RD
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33351-6005
Practice Address - Country:US
Practice Address - Phone:954-605-0378
Practice Address - Fax:954-530-4292
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-30
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24372126106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty