Provider Demographics
NPI:1023376019
Name:GRUNDVIG, MELISSA (LMT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:GRUNDVIG
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:699 S ANGEL ST
Mailing Address - Street 2:
Mailing Address - City:KAYSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84037-9756
Mailing Address - Country:US
Mailing Address - Phone:801-444-1298
Mailing Address - Fax:
Practice Address - Street 1:699 S ANGEL ST
Practice Address - Street 2:
Practice Address - City:KAYSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84037-9756
Practice Address - Country:US
Practice Address - Phone:801-444-1298
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-26
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6588630-4701225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist