Provider Demographics
NPI:1235648452
Name:GRILLION, GINA MICHELLE (MHS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:MICHELLE
Last Name:GRILLION
Suffix:
Gender:F
Credentials:MHS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 N WOODWORTH RD
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:IL
Mailing Address - Zip Code:60953-6254
Mailing Address - Country:US
Mailing Address - Phone:815-592-5980
Mailing Address - Fax:
Practice Address - Street 1:203 N THIRD ST
Practice Address - Street 2:
Practice Address - City:ASHKUM
Practice Address - State:IL
Practice Address - Zip Code:60911-6040
Practice Address - Country:US
Practice Address - Phone:815-698-2212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-20
Last Update Date:2017-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
146012682235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist