Healthcare Provider Details

I. General information

NPI: 1215564349
Provider Name (Legal Business Name): GRACE KELLY VALLEJO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2020
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

146 E HOSPITAL DR STE 120A
WEST COLUMBIA SC
29169-4800
US

IV. Provider business mailing address

PO BOX 405827
ATLANTA GA
30384-5827
US

V. Phone/Fax

Practice location:
  • Phone: 803-936-7460
  • Fax: 803-936-7462
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number93769
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number71490
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number4301512093
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: