Provider Demographics
NPI:1942475520
Name:GROMALA, HEATHER ANN (MA, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:ANN
Last Name:GROMALA
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:ANN
Other - Last Name:JOHNSTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:N3238 COUNTY ROAD RW
Mailing Address - Street 2:
Mailing Address - City:PESHTIGO
Mailing Address - State:WI
Mailing Address - Zip Code:54157-9609
Mailing Address - Country:US
Mailing Address - Phone:715-582-0196
Mailing Address - Fax:
Practice Address - Street 1:903 MAIN AVE
Practice Address - Street 2:
Practice Address - City:CRIVITZ
Practice Address - State:WI
Practice Address - Zip Code:54114-1619
Practice Address - Country:US
Practice Address - Phone:715-854-2717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-24
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2554-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42560000Medicaid
12046075OtherAMERICAN SPEECH LANGUAGE HEARING ASSOCIATION
WI2554-154OtherSTATE OF WISCONSIN DEPARTMENT OF REGULATION AND LICENSING