Healthcare Provider Details

I. General information

NPI: 1295626935
Provider Name (Legal Business Name): GRACE THOMAS MS CCC SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2025
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3230 S ADAMS AVE
MILWAUKEE WI
53207-2706
US

IV. Provider business mailing address

3230 S ADAMS AVE
MILWAUKEE WI
53207-2706
US

V. Phone/Fax

Practice location:
  • Phone: 414-294-1700
  • Fax:
Mailing address:
  • Phone: 414-294-1700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number6959154
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: