Provider Demographics
NPI:1033494026
Name:PETTIGREW, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:PETTIGREW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:OLDENBORG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:18 TOOMEY DR
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12603-4215
Mailing Address - Country:US
Mailing Address - Phone:845-240-1595
Mailing Address - Fax:
Practice Address - Street 1:18 TOOMEY DR
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12603-4215
Practice Address - Country:US
Practice Address - Phone:845-240-1595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-21
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016627235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist