Provider Demographics
NPI:1871232652
Name:PELLEGROM, ELIZABETH A (MA, LPC)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:A
Last Name:PELLEGROM
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18565 WOODDUCK DR
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49456-2901
Mailing Address - Country:US
Mailing Address - Phone:269-744-2604
Mailing Address - Fax:
Practice Address - Street 1:18565 WOODDUCK DR
Practice Address - Street 2:
Practice Address - City:SPRING LAKE
Practice Address - State:MI
Practice Address - Zip Code:49456-2901
Practice Address - Country:US
Practice Address - Phone:269-744-2604
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-01
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401008238101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional