Provider Demographics
NPI:1639766116
Name:CALKINS, GRACIELA PATINO
Entity Type:Individual
Prefix:
First Name:GRACIELA
Middle Name:PATINO
Last Name:CALKINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 GARLINGTON RD STE B5
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4621
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:319 GARLINGTON RD STE B5
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-4621
Practice Address - Country:US
Practice Address - Phone:864-417-8423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-30
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7474235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC465398874Medicaid