Provider Demographics
NPI:1679893697
Name:GRACE, SUSAN (DC)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:GRACE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-4001
Mailing Address - Country:US
Mailing Address - Phone:207-322-6933
Mailing Address - Fax:
Practice Address - Street 1:777 CONCORD AVE
Practice Address - Street 2:STE 301
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-1053
Practice Address - Country:US
Practice Address - Phone:617-876-6777
Practice Address - Fax:617-876-9011
Is Sole Proprietor?:No
Enumeration Date:2010-06-02
Last Update Date:2013-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3335111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor