Provider Demographics
NPI:1447671037
Name:GRACE-BRAUN, VIRGINIA
Entity type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:
Last Name:GRACE-BRAUN
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 1:225 PRESTON DR
Mailing Address - Street 2:
Mailing Address - City:CLOVERDALE
Mailing Address - State:CA
Mailing Address - Zip Code:95425-9511
Mailing Address - Country:US
Mailing Address - Phone:707-483-8013
Mailing Address - Fax:
Practice Address - Street 1:225 PRESTON DR
Practice Address - Street 2:
Practice Address - City:CLOVERDALE
Practice Address - State:CA
Practice Address - Zip Code:95425-9511
Practice Address - Country:US
Practice Address - Phone:707-483-8013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-27
Last Update Date:2013-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALPCC #397103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling