Provider Demographics
NPI:1891478434
Name:WATSON, GRACE
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:WATSON
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 1:18791 N 1330 EAST RD
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:IL
Mailing Address - Zip Code:61764-3379
Mailing Address - Country:US
Mailing Address - Phone:815-674-2661
Mailing Address - Fax:
Practice Address - Street 1:18791 N 1330 EAST RD
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:IL
Practice Address - Zip Code:61764-3379
Practice Address - Country:US
Practice Address - Phone:815-674-2661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-10
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist