Provider Demographics
NPI:1154502078
Name:GREGORASH, CHARYSSE M (MS-SLP)
Entity Type:Individual
Prefix:MISS
First Name:CHARYSSE
Middle Name:M
Last Name:GREGORASH
Suffix:
Gender:F
Credentials:MS-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3315 BEHRENS PKWY
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-1255
Mailing Address - Country:US
Mailing Address - Phone:920-803-1617
Mailing Address - Fax:920-803-1622
Practice Address - Street 1:3315 BEHRENS PKWY
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-1255
Practice Address - Country:US
Practice Address - Phone:920-803-1617
Practice Address - Fax:920-803-1622
Is Sole Proprietor?:No
Enumeration Date:2007-11-19
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1350-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41813000Medicaid
WI526588Medicare PIN