Healthcare Provider Details

I. General information

NPI: 1487487179
Provider Name (Legal Business Name): GRACIE HUMPHREY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2024
Last Update Date: 08/20/2024
Certification Date: 08/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3115 S GRAND BLVD STE 224
SAINT LOUIS MO
63118-1047
US

IV. Provider business mailing address

6325 VICTORIA AVE APT 408
SAINT LOUIS MO
63139-3166
US

V. Phone/Fax

Practice location:
  • Phone: 314-312-2357
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2024032588
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: