Provider Demographics
NPI:1104549831
Name:PORTENTOSO, GRACE NICHOLE NICATA
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:NICHOLE NICATA
Last Name:PORTENTOSO
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 1:1205 KING RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43617-2013
Mailing Address - Country:US
Mailing Address - Phone:419-867-5666
Mailing Address - Fax:
Practice Address - Street 1:1205 KING RD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43617-2013
Practice Address - Country:US
Practice Address - Phone:419-867-5666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-19
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOND.20222021-SP235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist