Provider Demographics
NPI:1578307070
Name:GRACE, UNKNOWN (RBAI)
Entity type:Individual
Prefix:
First Name:UNKNOWN
Middle Name:
Last Name:GRACE
Suffix:
Gender:F
Credentials:RBAI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12920 SW TAPADERA ST
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97008-7234
Mailing Address - Country:US
Mailing Address - Phone:503-380-0247
Mailing Address - Fax:
Practice Address - Street 1:18765 SW BOONES FERRY RD STE 100
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-8607
Practice Address - Country:US
Practice Address - Phone:503-673-1248
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-20
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORABA-IN-10246206106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician