Provider Demographics
NPI:1376021220
Name:RICHARDSON, GRACE (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4607 MANCHACA RD
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-1607
Mailing Address - Country:US
Mailing Address - Phone:512-916-1511
Mailing Address - Fax:512-916-1532
Practice Address - Street 1:4607 MANCHACA RD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-1607
Practice Address - Country:US
Practice Address - Phone:512-916-1511
Practice Address - Fax:512-916-1532
Is Sole Proprietor?:No
Enumeration Date:2018-08-02
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX114056235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist