Provider Demographics
NPI:1710139803
Name:GRANT, EVELYN BERGH (MA CCC/SLP)
Entity Type:Individual
Prefix:
First Name:EVELYN
Middle Name:BERGH
Last Name:GRANT
Suffix:
Gender:F
Credentials:MA CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4108 W 129TH ST
Mailing Address - Street 2:
Mailing Address - City:LEAWOOD
Mailing Address - State:KS
Mailing Address - Zip Code:66209-3308
Mailing Address - Country:US
Mailing Address - Phone:913-814-8066
Mailing Address - Fax:
Practice Address - Street 1:10000 W 75TH ST
Practice Address - Street 2:SUITE 250
Practice Address - City:MERRIAM
Practice Address - State:KS
Practice Address - Zip Code:66204-2209
Practice Address - Country:US
Practice Address - Phone:913-894-1910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-21
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS336235Z00000X
MO01559235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS336OtherSTATE LICENSE
MO01559OtherSTATE LICENSE