Provider Demographics
NPI:1013475276
Name:GIBSON, GRACE J (MA, CF-SLP)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:J
Last Name:GIBSON
Suffix:
Gender:F
Credentials:MA, CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 LAKE SHADOW CIR APT 3106
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7552
Mailing Address - Country:US
Mailing Address - Phone:321-615-7672
Mailing Address - Fax:
Practice Address - Street 1:4401 E COLONIAL DR STE 107
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-5200
Practice Address - Country:US
Practice Address - Phone:407-898-5060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-06
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ8540235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist