Provider Demographics
NPI:1396801304
Name:GRACE, JAMES A (PHD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:A
Last Name:GRACE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:JIM
Other - Middle Name:
Other - Last Name:GRACE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:10630 TOWN CENTER DRIVE
Mailing Address - Street 2:SUITE #124
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730
Mailing Address - Country:US
Mailing Address - Phone:909-949-6011
Mailing Address - Fax:909-948-8899
Practice Address - Street 1:10630 TOWN CENTER DRIVE
Practice Address - Street 2:SUITE #124
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730
Practice Address - Country:US
Practice Address - Phone:909-949-6011
Practice Address - Fax:909-948-8899
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12929103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY12929Medicaid
CAPSY12929Medicaid