Provider Demographics
NPI:1710463591
Name:GRANT, ALEXANDRIA ANASTASIA (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:ALEXANDRIA
Middle Name:ANASTASIA
Last Name:GRANT
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 1:9056 WATER TUPELO RD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-9006
Mailing Address - Country:US
Mailing Address - Phone:720-308-7171
Mailing Address - Fax:
Practice Address - Street 1:9731 COMMERCE CENTER CT
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-1400
Practice Address - Country:US
Practice Address - Phone:239-334-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-16
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA16138235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist