Provider Demographics
NPI:1306821418
Name:GRENELL, RICHARD H (PT)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:H
Last Name:GRENELL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1630 COMMANCHE AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313-5753
Mailing Address - Country:US
Mailing Address - Phone:920-430-4750
Mailing Address - Fax:
Practice Address - Street 1:1630 COMMANCHE AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54313-5753
Practice Address - Country:US
Practice Address - Phone:920-430-4750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-12
Last Update Date:2010-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3276225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3276-024OtherLICENSE
WV3276-024OtherLICENSE
WI000010Medicare Oscar/Certification
WI000045Medicare Oscar/Certification
WI000025Medicare Oscar/Certification
WI000028Medicare Oscar/Certification