Provider Demographics
NPI:1902248628
Name:DANIELS, GREGORY G
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:G
Last Name:DANIELS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:GREGORY
Other - Middle Name:G
Other - Last Name:DANIELS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA,CCC-SLP
Mailing Address - Street 1:1330 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48838-2190
Mailing Address - Country:US
Mailing Address - Phone:616-754-7040
Mailing Address - Fax:616-754-7888
Practice Address - Street 1:1330 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48838-2190
Practice Address - Country:US
Practice Address - Phone:616-754-7040
Practice Address - Fax:616-754-7888
Is Sole Proprietor?:No
Enumeration Date:2013-07-23
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI12057169235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI30435OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MI30435OtherBLUE CROSS BLUE SHIELD OF MICHIGAN