Basic Information
| Provider Information | |||||||||
| NPI: | 1881130151 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NICLOSI | ||||||||
| FirstName: | GRACE | ||||||||
| MiddleName: | NORCROSS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2111 W SWANN AVE | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336062477 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132511618 | ||||||||
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| Practice Location | |||||||||
| Address1: | 413 W TYLER AVE | ||||||||
| Address2: | |||||||||
| City: | WEST MEMPHIS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 723014149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8707331200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2017 | ||||||||
| LastUpdateDate: | 08/22/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.