Provider Demographics
NPI:1609125418
Name:GRANGER, HEATHER NICOLE (MED, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:NICOLE
Last Name:GRANGER
Suffix:
Gender:F
Credentials:MED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:156 SUMMER MEADOWS LN
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31757-0116
Mailing Address - Country:US
Mailing Address - Phone:229-244-1667
Mailing Address - Fax:229-244-8253
Practice Address - Street 1:2717 WINDEMERE DR
Practice Address - Street 2:SUITE E
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1686
Practice Address - Country:US
Practice Address - Phone:229-244-1667
Practice Address - Fax:229-244-8253
Is Sole Proprietor?:No
Enumeration Date:2012-09-07
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP007211235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist