Provider Demographics
NPI:1013096601
Name:WIECZOREK, GREGORY (MA,CCC/A)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:WIECZOREK
Suffix:
Gender:M
Credentials:MA,CCC/A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 DELZINGRO DR
Mailing Address - Street 2:
Mailing Address - City:DAVISON
Mailing Address - State:MI
Mailing Address - Zip Code:48423-2833
Mailing Address - Country:US
Mailing Address - Phone:810-658-7365
Mailing Address - Fax:
Practice Address - Street 1:3725 S SAGINAW ST
Practice Address - Street 2:STE 107
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-4321
Practice Address - Country:US
Practice Address - Phone:810-235-8750
Practice Address - Fax:810-235-9760
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI3501003346237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter