Provider Demographics
NPI:1740412725
Name:WILLIAMS, GRACE O (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:O
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 TILGHMAN FOREST DR
Mailing Address - Street 2:
Mailing Address - City:NORTH MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29582-2891
Mailing Address - Country:US
Mailing Address - Phone:843-280-5976
Mailing Address - Fax:
Practice Address - Street 1:921 TILGHMAN FOREST DR
Practice Address - Street 2:
Practice Address - City:NORTH MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29582-2891
Practice Address - Country:US
Practice Address - Phone:843-280-5976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-10
Last Update Date:2009-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC166235Z00000X
SC2856235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist