=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285252569
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY GRACEK M.A., CCC-SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/13/2020
-----------------------------------------------------
Last Update Date | 09/08/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 90 FORT WADE RD SUITE 100 #1017
-----------------------------------------------------
City | PONTE VEDRA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32081
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-834-9796
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 90 FORT WADE RD SUITE 100 #1017
-----------------------------------------------------
City | PONTE VEDRA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32081
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | SA20900
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 30002434
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------