Provider Demographics
NPI:1174673115
Name:GRANGER, MICHELLE JENNIFER (MS,CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:JENNIFER
Last Name:GRANGER
Suffix:
Gender:F
Credentials:MS,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Last Name Type:
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Mailing Address - Street 1:135 S GIBSON ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:WI
Mailing Address - Zip Code:54451-1622
Mailing Address - Country:US
Mailing Address - Phone:715-748-8100
Mailing Address - Fax:715-748-8199
Practice Address - Street 1:103 S GIBSON ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:WI
Practice Address - Zip Code:54451
Practice Address - Country:US
Practice Address - Phone:715-748-8112
Practice Address - Fax:715-748-8792
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2901-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist