Provider Demographics
NPI:1124367198
Name:CARLA TELLOR GRUNDY
Entity Type:Organization
Organization Name:CARLA TELLOR GRUNDY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:TELLOR
Authorized Official - Last Name:GRUNDY
Authorized Official - Suffix:
Authorized Official - Credentials:SLP
Authorized Official - Phone:314-452-4415
Mailing Address - Street 1:121 PARK RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63119-2528
Mailing Address - Country:US
Mailing Address - Phone:314-452-4415
Mailing Address - Fax:
Practice Address - Street 1:121 PARK RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63119-2528
Practice Address - Country:US
Practice Address - Phone:314-452-4415
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-11
Last Update Date:2013-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008022570251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care