Provider Demographics
NPI:1063068229
Name:DAVILA, GRACE
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:DAVILA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:GRACE
Other - Middle Name:
Other - Last Name:ROSARIO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:GRACE DAVILA
Mailing Address - Street 1:439 S UNION ST STE 104
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01843-2844
Mailing Address - Country:US
Mailing Address - Phone:978-648-8515
Mailing Address - Fax:978-648-8515
Practice Address - Street 1:7821 N DALE MABRY HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-3275
Practice Address - Country:US
Practice Address - Phone:813-443-4827
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-14
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
FLIMH23385101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator