Provider Demographics
NPI:1871074997
Name:CHANG, GRACE
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:CHANG
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 1:3183 WILSHIRE BLVD # 196D5
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010-1211
Mailing Address - Country:US
Mailing Address - Phone:213-787-7644
Mailing Address - Fax:
Practice Address - Street 1:10653 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91602-2341
Practice Address - Country:US
Practice Address - Phone:213-787-7644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2020-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225C00000X, 390200000X
CA31147103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program