Provider Demographics
NPI:1386610475
Name:GRADY, TERESA ELAINE
Entity type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:ELAINE
Last Name:GRADY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELAINE
Other - Middle Name:
Other - Last Name:GRADY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1571 RIVERTRACE DR
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32003-7778
Mailing Address - Country:US
Mailing Address - Phone:904-215-1242
Mailing Address - Fax:
Practice Address - Street 1:1571 RIVERTRACE DR
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32003-7778
Practice Address - Country:US
Practice Address - Phone:904-215-1242
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA6782235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist