Provider Demographics
NPI:1881130151
Name:NICLOSI, GRACE NORCROSS
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:NORCROSS
Last Name:NICLOSI
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 1:2111 W SWANN AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33606-2477
Mailing Address - Country:US
Mailing Address - Phone:813-251-1618
Mailing Address - Fax:
Practice Address - Street 1:413 W TYLER AVE
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-4149
Practice Address - Country:US
Practice Address - Phone:870-733-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-11
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist