Provider Demographics
NPI:1588154397
Name:STALEY, GRACIE FAYE
Entity type:Individual
Prefix:
First Name:GRACIE
Middle Name:FAYE
Last Name:STALEY
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 1:1001 W SW LOOP 323
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-9416
Mailing Address - Country:US
Mailing Address - Phone:430-205-8710
Mailing Address - Fax:
Practice Address - Street 1:1001 W SW LOOP 323
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-9416
Practice Address - Country:US
Practice Address - Phone:430-205-8710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-16
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-19-97738106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician