Provider Demographics
NPI:1003413774
Name:PELLEGRINO, MIKEAYLA
Entity Type:Individual
Prefix:
First Name:MIKEAYLA
Middle Name:
Last Name:PELLEGRINO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 E MANSION ST RICKETSON BUILDING
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49068
Mailing Address - Country:US
Mailing Address - Phone:269-789-8982
Mailing Address - Fax:
Practice Address - Street 1:103 E MANSION ST RICKETSON BUILDING
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MI
Practice Address - Zip Code:49068
Practice Address - Country:US
Practice Address - Phone:269-789-8982
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-06
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7151013295235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist