Provider Demographics
NPI:1104186147
Name:GRUMBLES, SALLY
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:GRUMBLES
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 1:30 BELLVIEW RDG
Mailing Address - Street 2:
Mailing Address - City:SHARPSBURG
Mailing Address - State:GA
Mailing Address - Zip Code:30277-1556
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30 BELLVIEW RDG
Practice Address - Street 2:
Practice Address - City:SHARPSBURG
Practice Address - State:GA
Practice Address - Zip Code:30277-1556
Practice Address - Country:US
Practice Address - Phone:770-463-3413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-24
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA382839235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist