Provider Demographics
NPI:1588781876
Name:SLACK, GRACE (OTR)
Entity type:Individual
Prefix:MRS
First Name:GRACE
Middle Name:
Last Name:SLACK
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5252 LAKE WYLIE RD
Mailing Address - Street 2:
Mailing Address - City:LAKE WYLIE
Mailing Address - State:SC
Mailing Address - Zip Code:29710-9181
Mailing Address - Country:US
Mailing Address - Phone:803-412-7104
Mailing Address - Fax:
Practice Address - Street 1:10508 PARK RD
Practice Address - Street 2:SUITE 130
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-8525
Practice Address - Country:US
Practice Address - Phone:704-541-9080
Practice Address - Fax:704-542-0699
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2009-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3233225X00000X
NC6575225XP0200X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist