Provider Demographics
NPI:1114446812
Name:GRINNELL, KEVIN PAUL
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:PAUL
Last Name:GRINNELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5740 NE 22ND AVE
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34479-7162
Mailing Address - Country:US
Mailing Address - Phone:352-426-7072
Mailing Address - Fax:
Practice Address - Street 1:16414 LAKE CHURCH DR
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:FL
Practice Address - Zip Code:33556-2637
Practice Address - Country:US
Practice Address - Phone:720-340-1321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-13
Last Update Date:2017-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician