Provider Demographics
NPI:1912024035
Name:FORD, GRACE SUSIE (PHD)
Entity Type:Individual
Prefix:DR
First Name:GRACE
Middle Name:SUSIE
Last Name:FORD
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:GRACE
Other - Middle Name:CORUM
Other - Last Name:FORD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:2424 DOUBLE CHURCHES RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909-2741
Mailing Address - Country:US
Mailing Address - Phone:706-326-3301
Mailing Address - Fax:706-327-7592
Practice Address - Street 1:2424 DOUBLE CHURCHES RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909-2741
Practice Address - Country:US
Practice Address - Phone:706-326-3301
Practice Address - Fax:706-327-7592
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP000323235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA344464474AMedicaid
GA52265958OtherBLUE CROSS BLUE SHIELD #
GA344464474AMedicaid