Provider Demographics
NPI:1851844047
Name:GRACE, ANGELA (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:GRACE
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 1:1870 BETHESDA RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHERN PINES
Mailing Address - State:NC
Mailing Address - Zip Code:28387-6479
Mailing Address - Country:US
Mailing Address - Phone:505-715-3330
Mailing Address - Fax:
Practice Address - Street 1:407 E 65TH ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-4332
Practice Address - Country:US
Practice Address - Phone:505-715-3330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-25
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC15408235Z00000X
GASLP009314235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist