Provider Demographics
NPI:1053001198
Name:BOLEN, GRACE ELIZABETH
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:ELIZABETH
Last Name:BOLEN
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 1:2828 FORD ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94601-2114
Mailing Address - Country:US
Mailing Address - Phone:510-268-3770
Mailing Address - Fax:
Practice Address - Street 1:2828 FORD ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94601-2114
Practice Address - Country:US
Practice Address - Phone:510-268-3770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-11
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CA141906106H00000X
CA14728101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional