Provider Demographics
NPI:1043312663
Name:O'GRADY, ELIZABETH JANE (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:JANE
Last Name:O'GRADY
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7955 MOUNT RANIER DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-2906
Mailing Address - Country:US
Mailing Address - Phone:904-652-5408
Mailing Address - Fax:904-997-6478
Practice Address - Street 1:11512 LAKE MEAD AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-9680
Practice Address - Country:US
Practice Address - Phone:904-652-5408
Practice Address - Fax:904-997-6478
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-03
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA5968235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
043816841OtherTAX IDENTIFICATION NUMBER