Provider Demographics
NPI:1285429837
Name:MAN, GRACE
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:MAN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2412 KESTRAL BLVD APT G
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47906-6529
Mailing Address - Country:US
Mailing Address - Phone:217-418-8517
Mailing Address - Fax:
Practice Address - Street 1:2701 CHESTNUT STATION CT
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40299-6395
Practice Address - Country:US
Practice Address - Phone:800-335-1060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-14
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22009134A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist