Provider Demographics
NPI:1902592298
Name:MATTES, GRACE N (APCC)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:N
Last Name:MATTES
Suffix:
Gender:F
Credentials:APCC
Other - Prefix:
Other - First Name:GRACE
Other - Middle Name:N
Other - Last Name:HEYNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2001 OLYMPIC BLVD APT 206
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-3959
Mailing Address - Country:US
Mailing Address - Phone:763-458-9276
Mailing Address - Fax:
Practice Address - Street 1:4221 WILSHIRE BLVD STE 230
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-3554
Practice Address - Country:US
Practice Address - Phone:213-505-4307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-11
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAPCC12639101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health