Provider Demographics
NPI:1366694499
Name:OLIVER, GRACE (CCC/SLP)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:OLIVER
Suffix:
Gender:F
Credentials:CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 RIVERSIDE AVE.
Mailing Address - Street 2:C-6
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06905-4433
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:85 RIVERSIDE AVE.
Practice Address - Street 2:C-6
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-4433
Practice Address - Country:US
Practice Address - Phone:203-324-5482
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-21
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008851-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist