Provider Demographics
NPI:1679278246
Name:GRACE, NICHOLAS
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:GRACE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:NICHOLAS
Other - Middle Name:
Other - Last Name:MARTINEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2000 W BRIGGSMORE AVE STE I
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-3839
Mailing Address - Country:US
Mailing Address - Phone:209-526-1476
Mailing Address - Fax:
Practice Address - Street 1:2000 W BRIGGSMORE AVE STE I
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-3839
Practice Address - Country:US
Practice Address - Phone:209-526-1476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-03
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17828101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional