Provider Demographics
NPI:1699109488
Name:GREGG, PENNY (MS/CCC-SLP)
Entity type:Individual
Prefix:
First Name:PENNY
Middle Name:
Last Name:GREGG
Suffix:
Gender:F
Credentials:MS/CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N1192 BALL RD
Mailing Address - Street 2:
Mailing Address - City:VULCAN
Mailing Address - State:MI
Mailing Address - Zip Code:49892-8675
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:N1192 BALL RD
Practice Address - Street 2:
Practice Address - City:VULCAN
Practice Address - State:MI
Practice Address - Zip Code:49892-8675
Practice Address - Country:US
Practice Address - Phone:906-563-8870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-28
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI9145946235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist