Provider Demographics
NPI:1932648839
Name:SLABACH, GRETA (OTR)
Entity Type:Individual
Prefix:
First Name:GRETA
Middle Name:
Last Name:SLABACH
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 SOUTHERN CROSS DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURY
Mailing Address - State:IN
Mailing Address - Zip Code:46540
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:205 SOUTHERN CROSS DR
Practice Address - Street 2:
Practice Address - City:MIDDLEBURY
Practice Address - State:IN
Practice Address - Zip Code:46540
Practice Address - Country:US
Practice Address - Phone:574-370-1676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-13
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEU1-0001748405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional