Provider Demographics
NPI:1114620291
Name:PANTALONE, GRACE
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:PANTALONE
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 1:123 S 7TH ST
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80905-1602
Mailing Address - Country:US
Mailing Address - Phone:405-517-5035
Mailing Address - Fax:
Practice Address - Street 1:830 TENDERFOOT HILL RD STE 100
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-7372
Practice Address - Country:US
Practice Address - Phone:888-611-0870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-27
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COBACB708149103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst