Provider Demographics
NPI:1376266817
Name:RAHTJEN, GRACE ELLEN (HIS)
Entity Type:Individual
Prefix:MRS
First Name:GRACE
Middle Name:ELLEN
Last Name:RAHTJEN
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:MISS
Other - First Name:GRACE
Other - Middle Name:ELLEN
Other - Last Name:PIERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:919 PRIVATE ROAD 1712
Mailing Address - Street 2:
Mailing Address - City:MICO
Mailing Address - State:TX
Mailing Address - Zip Code:78056-5571
Mailing Address - Country:US
Mailing Address - Phone:785-370-2777
Mailing Address - Fax:
Practice Address - Street 1:1112 S MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:BOERNE
Practice Address - State:TX
Practice Address - Zip Code:78006-2812
Practice Address - Country:US
Practice Address - Phone:308-609-9056
Practice Address - Fax:830-893-0132
Is Sole Proprietor?:No
Enumeration Date:2022-09-20
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX81000237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX81000OtherTEXAS DEPARTMENT OF LICENSING AND REGULATION