Basic Information
| Provider Information | |||||||||
| NPI: | 1710139803 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRANT | ||||||||
| FirstName: | EVELYN | ||||||||
| MiddleName: | BERGH | ||||||||
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| Credential: | M.A. CCC/SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4108 W 129TH ST | ||||||||
| Address2: | |||||||||
| City: | LEAWOOD | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662093308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9138148066 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10000 W 75TH ST | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | MERRIAM | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662042209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9138941910 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2008 | ||||||||
| LastUpdateDate: | 10/21/2008 | ||||||||
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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 | 336 | KS | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | 01559 | MO | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 336 | 01 | KS | STATE LICENSE | OTHER | 01559 | 01 | MO | STATE LICENSE | OTHER |