Provider Demographics
NPI:1407217722
Name:GRINDSTAFF, MELISSA
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:GRINDSTAFF
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 1:5135 FRANCES AVE NE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98422-1837
Mailing Address - Country:US
Mailing Address - Phone:253-350-3412
Mailing Address - Fax:
Practice Address - Street 1:15445 53RD AVE S STE 110
Practice Address - Street 2:
Practice Address - City:TUKWILA
Practice Address - State:WA
Practice Address - Zip Code:98188-2326
Practice Address - Country:US
Practice Address - Phone:206-313-8840
Practice Address - Fax:206-641-9540
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-14
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA111524501Medicaid