Provider Demographics
NPI:1447714472
Name:GRADE, ELLEN REBECCA
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:REBECCA
Last Name:GRADE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 26TH ST NW APT 6207
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-1929
Mailing Address - Country:US
Mailing Address - Phone:678-910-5404
Mailing Address - Fax:
Practice Address - Street 1:3105 CREEKSIDE VILLAGE DR NW STE 604
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-4218
Practice Address - Country:US
Practice Address - Phone:770-974-2424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-23
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP009786235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist