Provider Demographics
NPI:1194268623
Name:GRACE, AVERY (QMHP)
Entity type:Individual
Prefix:
First Name:AVERY
Middle Name:
Last Name:GRACE
Suffix:
Gender:F
Credentials:QMHP
Other - Prefix:
Other - First Name:AVERY
Other - Middle Name:
Other - Last Name:ERICKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC, MS
Mailing Address - Street 1:1058 NE 12TH ST
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-4412
Mailing Address - Country:US
Mailing Address - Phone:541-678-5320
Mailing Address - Fax:
Practice Address - Street 1:1058 NE 12TH ST
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-4412
Practice Address - Country:US
Practice Address - Phone:541-678-5320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-01
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17331171100000X
OR22-QMHP-R-1292101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171100000XOther Service ProvidersAcupuncturist