Provider Demographics
NPI:1902049208
Name:WORTHINGTON, GRETA MARIE (MS,CCC-SLP)
Entity Type:Individual
Prefix:
First Name:GRETA
Middle Name:MARIE
Last Name:WORTHINGTON
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 1:77 MOUNT SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73507-9009
Mailing Address - Country:US
Mailing Address - Phone:580-574-0573
Mailing Address - Fax:
Practice Address - Street 1:1507 W GORE BLVD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73501-3608
Practice Address - Country:US
Practice Address - Phone:580-574-0573
Practice Address - Fax:580-529-2917
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-16
Last Update Date:2009-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1046235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist