Provider Demographics
NPI:1639337926
Name:GRADY, RENEE M (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:M
Last Name:GRADY
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 1:1 BENTON CIR
Mailing Address - Street 2:
Mailing Address - City:LONOKE
Mailing Address - State:AR
Mailing Address - Zip Code:72086-3624
Mailing Address - Country:US
Mailing Address - Phone:501-676-0038
Mailing Address - Fax:
Practice Address - Street 1:1 BENTON CIR
Practice Address - Street 2:
Practice Address - City:LONOKE
Practice Address - State:AR
Practice Address - Zip Code:72086-3624
Practice Address - Country:US
Practice Address - Phone:501-676-0038
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-23
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP# 679235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR125535721Medicaid