Provider Demographics
NPI:1134409626
Name:LAM, GRACE (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:LAM
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 1:188 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92782-6515
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14851 YORBA ST
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-2925
Practice Address - Country:US
Practice Address - Phone:714-573-5382
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-28
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18152235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist