Provider Demographics
NPI:1790107449
Name:CARTER, GRACE
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:CARTER
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 1:1591 RIVERS RD
Mailing Address - Street 2:
Mailing Address - City:GREEN COVE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32043-9389
Mailing Address - Country:US
Mailing Address - Phone:904-501-1453
Mailing Address - Fax:
Practice Address - Street 1:803 OAK ST
Practice Address - Street 2:
Practice Address - City:GREEN COVE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32043-4317
Practice Address - Country:US
Practice Address - Phone:904-284-5606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-15
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24646225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant