Healthcare Provider Details

I. General information

NPI: 1881072411
Provider Name (Legal Business Name): GRACE THERAPIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2015
Last Update Date: 05/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4715 KIRBY LOOP RD
FORT PIERCE FL
34981-5345
US

IV. Provider business mailing address

10470 SW WATERWAY LN
PORT SAINT LUCIE FL
34987-2494
US

V. Phone/Fax

Practice location:
  • Phone: 772-461-9954
  • Fax:
Mailing address:
  • Phone: 772-812-0491
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License NumberSI 2529
License Number StateFL

VIII. Authorized Official

Name: MISS EMILY ANN SORICELLI
Title or Position: SPEECH-LANGUAGE PATHOLOGIST ASST
Credential: SLPA
Phone: 772-812-0491