Provider Demographics
NPI:1598168262
Name:GREGORY, DANIELLE
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:GREGORY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3940 CAMELOT DR SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-6006
Mailing Address - Country:US
Mailing Address - Phone:616-490-1499
Mailing Address - Fax:
Practice Address - Street 1:1450 LEONARD ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-5515
Practice Address - Country:US
Practice Address - Phone:616-774-8789
Practice Address - Fax:616-776-1305
Is Sole Proprietor?:No
Enumeration Date:2014-10-08
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6803086666171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator