Provider Demographics
NPI:1205374469
Name:GREGORY, MARYANNE VONINS (CPRM-M)
Entity Type:Individual
Prefix:
First Name:MARYANNE
Middle Name:VONINS
Last Name:GREGORY
Suffix:
Gender:F
Credentials:CPRM-M
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 E SOUTHERN AVE
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49442-5041
Mailing Address - Country:US
Mailing Address - Phone:231-726-3582
Mailing Address - Fax:231-722-3369
Practice Address - Street 1:125 E SOUTHERN AVE
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49442-5041
Practice Address - Country:US
Practice Address - Phone:231-726-3582
Practice Address - Fax:231-722-3369
Is Sole Proprietor?:No
Enumeration Date:2017-02-08
Last Update Date:2017-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MI175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician