Provider Demographics
NPI:1346427721
Name:GRACE, SABRINA LYNNE (MS CCC-S)
Entity Type:Individual
Prefix:MRS
First Name:SABRINA
Middle Name:LYNNE
Last Name:GRACE
Suffix:
Gender:F
Credentials:MS CCC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:765 DANS BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSON
Mailing Address - State:WV
Mailing Address - Zip Code:25661-9122
Mailing Address - Country:US
Mailing Address - Phone:304-235-4099
Mailing Address - Fax:
Practice Address - Street 1:506 HOLLY AVE
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:WV
Practice Address - Zip Code:25601-3306
Practice Address - Country:US
Practice Address - Phone:304-792-2073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-28
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV12026074235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA3810010957Medicaid