Provider Demographics
NPI:1306488002
Name:TAM, GRACE
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:TAM
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 1:2511 CORINTH AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-3013
Mailing Address - Country:US
Mailing Address - Phone:310-597-0161
Mailing Address - Fax:
Practice Address - Street 1:1111 BAKER ST
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-4138
Practice Address - Country:US
Practice Address - Phone:949-910-6767
Practice Address - Fax:677-268-3922
Is Sole Proprietor?:No
Enumeration Date:2019-10-14
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician