Provider Demographics
NPI:1326479080
Name:GRISSOM, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:GRISSOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13585 ELKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-5232
Mailing Address - Country:US
Mailing Address - Phone:952-451-4575
Mailing Address - Fax:
Practice Address - Street 1:6776 LAKE DRIVE
Practice Address - Street 2:ADVANCE THERAPY
Practice Address - City:LINO LAKES
Practice Address - State:MN
Practice Address - Zip Code:55014
Practice Address - Country:US
Practice Address - Phone:651-498-2071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-06
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN251272235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist