Provider Demographics
NPI:1356739775
Name:GRISDELA, HOLLY
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:GRISDELA
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 1:6500 CHAMPION GRANDVIEW WAY
Mailing Address - Street 2:40106
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78750-8223
Mailing Address - Country:US
Mailing Address - Phone:810-923-1242
Mailing Address - Fax:
Practice Address - Street 1:6500 CHAMPION GRANDVIEW WAY APT 40106
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78750-8438
Practice Address - Country:US
Practice Address - Phone:810-923-1242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-07
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110830235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist