Provider Demographics
NPI:1063664712
Name:GRIFFIN, KIM (LMT)
Entity Type:Individual
Prefix:MS
First Name:KIM
Middle Name:
Last Name:GRIFFIN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:MS
Other - First Name:KIM
Other - Middle Name:
Other - Last Name:GRIFFIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:14364 BENTLER ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48223-2608
Mailing Address - Country:US
Mailing Address - Phone:313-740-1446
Mailing Address - Fax:
Practice Address - Street 1:14364 BENTLER ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48223-2608
Practice Address - Country:US
Practice Address - Phone:313-740-1446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-14
Last Update Date:2008-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIBUS2008-00642225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist