Provider Demographics
NPI:1275100513
Name:CEBALT, GRACE ELAINE (AUD)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:ELAINE
Last Name:CEBALT
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1335 GETZ RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-1609
Mailing Address - Country:US
Mailing Address - Phone:260-436-6400
Mailing Address - Fax:
Practice Address - Street 1:1335 GETZ RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-1609
Practice Address - Country:US
Practice Address - Phone:260-436-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-07
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN23002749A231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN7657608894Medicaid