Provider Demographics
NPI:1326398124
Name:STRAIT-GILG, GRACIE MAE (SLP)
Entity Type:Individual
Prefix:
First Name:GRACIE
Middle Name:MAE
Last Name:STRAIT-GILG
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4710 CHANTERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43231-5946
Mailing Address - Country:US
Mailing Address - Phone:702-758-6986
Mailing Address - Fax:
Practice Address - Street 1:7690 NEW MARKET CENTER WAY
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43235-1976
Practice Address - Country:US
Practice Address - Phone:614-602-6473
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-19
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
NVSP-1473235Z00000X
AZSLP8288235Z00000X
OHSP.12430235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0236658Medicaid