Provider Demographics
NPI:1932640869
Name:KALISKY, GRACE (MA CCC SLP)
Entity Type:Individual
Prefix:MS
First Name:GRACE
Middle Name:
Last Name:KALISKY
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 1:12124 W FERAMORZ LN
Mailing Address - Street 2:
Mailing Address - City:STAR
Mailing Address - State:ID
Mailing Address - Zip Code:83669-5165
Mailing Address - Country:US
Mailing Address - Phone:208-391-2773
Mailing Address - Fax:855-255-0774
Practice Address - Street 1:12124 W FERAMORZ LN
Practice Address - Street 2:
Practice Address - City:STAR
Practice Address - State:ID
Practice Address - Zip Code:83669-5165
Practice Address - Country:US
Practice Address - Phone:208-391-2773
Practice Address - Fax:855-255-0774
Is Sole Proprietor?:No
Enumeration Date:2017-03-10
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-1678235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDNONEOtherNONE