Provider Demographics
NPI:1861046344
Name:PETTINGA, HANNAH (MA CCC-SLP)
Entity type:Individual
Prefix:
First Name:HANNAH
Middle Name:
Last Name:PETTINGA
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:351 JAMES AVE SE # LEVEL1
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4732
Mailing Address - Country:US
Mailing Address - Phone:616-610-1960
Mailing Address - Fax:
Practice Address - Street 1:7086 8TH AVE
Practice Address - Street 2:
Practice Address - City:JENISON
Practice Address - State:MI
Practice Address - Zip Code:49428-9352
Practice Address - Country:US
Practice Address - Phone:616-667-9551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-01
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101006401235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist