Provider Demographics
NPI:1528467545
Name:GRACE, EMILY (MAT, ATC)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:GRACE
Suffix:
Gender:F
Credentials:MAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:665 S SKINKER BLVD APT 9E
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63105-2347
Mailing Address - Country:US
Mailing Address - Phone:920-655-8688
Mailing Address - Fax:
Practice Address - Street 1:10407 CLAYTON RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2909
Practice Address - Country:US
Practice Address - Phone:314-692-0445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-14
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20140226042255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty