Provider Demographics
NPI:1285188839
Name:GRACE HEARING AND LANGUAGE SERVICES, LLC
Entity Type:Organization
Organization Name:GRACE HEARING AND LANGUAGE SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUDIOLOGIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHELLE
Authorized Official - Middle Name:J
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:AUD
Authorized Official - Phone:762-333-4400
Mailing Address - Street 1:3400 CHAPEL HILL RD
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-1739
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3400 CHAPEL HILL RD
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-1739
Practice Address - Country:US
Practice Address - Phone:678-741-5310
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-12
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004014261QH0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1730632290OtherNPPES INDIVIDUAL