Provider Demographics
NPI:1982438479
Name:SQUARE, GRACIELLA G
Entity type:Individual
Prefix:
First Name:GRACIELLA
Middle Name:G
Last Name:SQUARE
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 1:1250 SANTA CORA AVE APT 735
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91913-1556
Mailing Address - Country:US
Mailing Address - Phone:619-410-3680
Mailing Address - Fax:
Practice Address - Street 1:1771 E FLAMINGO RD STE 220AV
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-5155
Practice Address - Country:US
Practice Address - Phone:619-410-3680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-28
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician