Provider Demographics
NPI:1447476494
Name:GRANT, QUINCIE (MSE CCC-SLP)
Entity type:Individual
Prefix:
First Name:QUINCIE
Middle Name:
Last Name:GRANT
Suffix:
Gender:F
Credentials:MSE CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2604 POST OAK ST
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-5652
Mailing Address - Country:US
Mailing Address - Phone:870-926-8689
Mailing Address - Fax:
Practice Address - Street 1:2604 POST OAK ST
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-5652
Practice Address - Country:US
Practice Address - Phone:870-926-8689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP#457235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARSP 5Y396OtherBCBS NUMBER
AR156873721Medicaid
AR430037181OtherTRICARE HUMANA