Provider Demographics
NPI:1831697465
Name:GRISSOM-DUBENCO, MEGAN ANN (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:MEGAN
Middle Name:ANN
Last Name:GRISSOM-DUBENCO
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:MS
Other - First Name:MEGAN
Other - Middle Name:ANN
Other - Last Name:GRISSOM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:473 W ARMY TRAIL RD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:60108-2674
Mailing Address - Country:US
Mailing Address - Phone:224-520-8562
Mailing Address - Fax:215-318-1772
Practice Address - Street 1:473 W ARMY TRAIL RD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:60108-2674
Practice Address - Country:US
Practice Address - Phone:224-520-8562
Practice Address - Fax:215-318-1772
Is Sole Proprietor?:No
Enumeration Date:2018-01-29
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVSP-2076235Z00000X
IL146014880235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist