Provider Demographics
NPI:1366084881
Name:KIPENDO, GRACE
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:KIPENDO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4507 LIPAN ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80211-2448
Mailing Address - Country:US
Mailing Address - Phone:720-837-0884
Mailing Address - Fax:
Practice Address - Street 1:4507 LIPAN ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80211-2448
Practice Address - Country:US
Practice Address - Phone:720-837-0884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-16
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
COG869461Medicaid