Healthcare Provider Details

I. General information

NPI: 1730966391
Provider Name (Legal Business Name): GEORGIANNA RENE ZAGRZEBSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GEORGIANNA RENE PRATLEY

II. Dates (important events)

Enumeration Date: 09/08/2023
Last Update Date: 09/14/2023
Certification Date: 09/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3905 LORRAINE PATH
SAINT JOSEPH MI
49085-8630
US

IV. Provider business mailing address

1412 UNION PARK DR
VICKSBURG MI
49097-7766
US

V. Phone/Fax

Practice location:
  • Phone: 269-428-1111
  • Fax:
Mailing address:
  • Phone: 269-589-5088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number7152000766
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: