Provider Demographics
NPI:1992247381
Name:GRACE, KESHA ELAINE
Entity type:Individual
Prefix:
First Name:KESHA
Middle Name:ELAINE
Last Name:GRACE
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 1:118 W 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:KS
Mailing Address - Zip Code:67156-2852
Mailing Address - Country:US
Mailing Address - Phone:620-402-6641
Mailing Address - Fax:202-213-3506
Practice Address - Street 1:118 W 9TH AVE
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:KS
Practice Address - Zip Code:67156-2852
Practice Address - Country:US
Practice Address - Phone:620-402-6641
Practice Address - Fax:620-221-3350
Is Sole Proprietor?:No
Enumeration Date:2016-11-16
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8983104100000X
171M00000X
KS13289104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator