Provider Demographics
NPI:1396266607
Name:WONG, GRACE MAO
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:MAO
Last Name:WONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:GRACE
Other - Middle Name:YIJOU
Other - Last Name:MAO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6980 ROSWELL RD UNIT C7
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-2273
Mailing Address - Country:US
Mailing Address - Phone:678-315-4005
Mailing Address - Fax:
Practice Address - Street 1:6980 ROSWELL RD UNIT C7
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-2273
Practice Address - Country:US
Practice Address - Phone:678-315-4005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPCET002523235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty