Provider Demographics
NPI:1265019194
Name:GRINNELL, MIKAYLA (RBT)
Entity Type:Individual
Prefix:
First Name:MIKAYLA
Middle Name:
Last Name:GRINNELL
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2475 W CHICAGO ST
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-2467
Mailing Address - Country:US
Mailing Address - Phone:605-206-5004
Mailing Address - Fax:605-646-4840
Practice Address - Street 1:2475 W CHICAGO ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-2467
Practice Address - Country:US
Practice Address - Phone:605-206-5004
Practice Address - Fax:605-646-4840
Is Sole Proprietor?:No
Enumeration Date:2021-03-26
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-21-161158106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician