Provider Demographics
NPI:1962156463
Name:BENNETT, GRACE ANN
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:ANN
Last Name:BENNETT
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 1:834 W 26TH ST APT 1
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23517-1161
Mailing Address - Country:US
Mailing Address - Phone:703-927-7198
Mailing Address - Fax:
Practice Address - Street 1:3491 KURTZ ST STE 150
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-4430
Practice Address - Country:US
Practice Address - Phone:619-320-2404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-04
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARBT-21-191880106S00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician