Provider Demographics
NPI:1104515675
Name:GRACE, BRIAN (BCBA)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:GRACE
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1418 NE LITTLE BEAVER DR
Mailing Address - Street 2:
Mailing Address - City:GRIMES
Mailing Address - State:IA
Mailing Address - Zip Code:50111-4506
Mailing Address - Country:US
Mailing Address - Phone:480-466-1349
Mailing Address - Fax:
Practice Address - Street 1:2825 S ANKENY BLVD
Practice Address - Street 2:
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50023-9417
Practice Address - Country:US
Practice Address - Phone:515-598-7200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-02
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst