Healthcare Provider Details

I. General information

NPI: 1942475520
Provider Name (Legal Business Name): HEATHER ANN GROMALA MA, CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: HEATHER ANN JOHNSTON

II. Dates (important events)

Enumeration Date: 04/24/2008
Last Update Date: 04/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

903 MAIN AVE
CRIVITZ WI
54114-1619
US

IV. Provider business mailing address

N3238 COUNTY ROAD RW
PESHTIGO WI
54157-9609
US

V. Phone/Fax

Practice location:
  • Phone: 715-854-2717
  • Fax:
Mailing address:
  • Phone: 715-582-0196
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2554-154
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: