Provider Demographics
NPI:1003457300
Name:GRISSMAN, DANIETA KAY (PTA)
Entity Type:Individual
Prefix:MRS
First Name:DANIETA
Middle Name:KAY
Last Name:GRISSMAN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12460 WOODS EDGE TRL
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-9408
Mailing Address - Country:US
Mailing Address - Phone:817-637-0368
Mailing Address - Fax:
Practice Address - Street 1:12460 WOODS EDGE TRL
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-9408
Practice Address - Country:US
Practice Address - Phone:817-637-0368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-08
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2047777225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist