Provider Demographics
NPI:1831672807
Name:SOUTHWORTH, GRACE MARGUERITE (SLP)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:MARGUERITE
Last Name:SOUTHWORTH
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 LOWELL DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11735-3107
Mailing Address - Country:US
Mailing Address - Phone:516-395-6168
Mailing Address - Fax:
Practice Address - Street 1:260 PLEASANT AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-1798
Practice Address - Country:US
Practice Address - Phone:212-876-4639
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-14
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027992-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist