Provider Demographics
NPI:1255084190
Name:GYAN, GRACE
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:GYAN
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 1:725 N DOBSON RD APT 138
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-9104
Mailing Address - Country:US
Mailing Address - Phone:614-432-4351
Mailing Address - Fax:
Practice Address - Street 1:36019 W SAN CLEMENTE AVE
Practice Address - Street 2:
Practice Address - City:MARICOPA
Practice Address - State:AZ
Practice Address - Zip Code:85138-2118
Practice Address - Country:US
Practice Address - Phone:602-816-5618
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-01
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities