Provider Demographics
NPI:1154038065
Name:EDMOND, GRACE (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:EDMOND
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 W RED OAK RD
Mailing Address - Street 2:
Mailing Address - City:RED OAK
Mailing Address - State:TX
Mailing Address - Zip Code:75154-6335
Mailing Address - Country:US
Mailing Address - Phone:972-617-3523
Mailing Address - Fax:
Practice Address - Street 1:109 W RED OAK RD
Practice Address - Street 2:
Practice Address - City:RED OAK
Practice Address - State:TX
Practice Address - Zip Code:75154-6335
Practice Address - Country:US
Practice Address - Phone:972-617-3523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-31
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX235Z00000XMedicaid