Healthcare Provider Details

I. General information

NPI: 1093620353
Provider Name (Legal Business Name): GRACIE EILLEEN WEIDMAN M.S., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2026
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 SORENSON ST
NORTH LITTLE ROCK AR
72118-3473
US

IV. Provider business mailing address

304 SORENSON ST
NORTH LITTLE ROCK AR
72118-3473
US

V. Phone/Fax

Practice location:
  • Phone: 501-246-5191
  • Fax:
Mailing address:
  • Phone: 479-719-8750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number203699
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: