Provider Demographics
NPI:1194925594
Name:GRACE, GWENDOLYN GREGORY (MD)
Entity type:Individual
Prefix:DR
First Name:GWENDOLYN
Middle Name:GREGORY
Last Name:GRACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:GWENDOLYN
Other - Middle Name:GREGORY
Other - Last Name:GREER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:75 MANHATTAN DR
Mailing Address - Street 2:SUITE 204
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-4254
Mailing Address - Country:US
Mailing Address - Phone:303-569-8858
Mailing Address - Fax:303-647-9214
Practice Address - Street 1:75 MANHATTAN DR
Practice Address - Street 2:SUITE 204
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-4254
Practice Address - Country:US
Practice Address - Phone:303-569-8858
Practice Address - Fax:303-647-9214
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-23
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.478602084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry