Provider Demographics
NPI:1760846943
Name:GRODECKY, ROBIN (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ROBIN
Middle Name:
Last Name:GRODECKY
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 1:491 SEARLE AVE SW
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32908-6236
Mailing Address - Country:US
Mailing Address - Phone:321-794-7724
Mailing Address - Fax:
Practice Address - Street 1:491 SEARLE AVE SW
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32908-6236
Practice Address - Country:US
Practice Address - Phone:321-794-7724
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-13
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 12823235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist