Healthcare Provider Details

I. General information

NPI: 1134483142
Provider Name (Legal Business Name): LAURA B GRIZZARD M.A. CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2012
Last Update Date: 01/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 PROVIDENCE RD SUITE 80
VIRGINIA BEACH VA
23464-4128
US

IV. Provider business mailing address

5301 PROVIDENCE RD SUITE 80
VIRGINIA BEACH VA
23464-4128
US

V. Phone/Fax

Practice location:
  • Phone: 757-467-1900
  • Fax: 757-467-7900
Mailing address:
  • Phone: 757-467-1900
  • Fax: 757-467-7900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2202005670
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: