Provider Demographics
NPI:1417351826
Name:GRILL-EWING, STACY
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:GRILL-EWING
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 1:1550 3 MILE RD NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49544-8251
Mailing Address - Country:US
Mailing Address - Phone:616-785-8535
Mailing Address - Fax:
Practice Address - Street 1:388 GARDEN AVE
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-8998
Practice Address - Country:US
Practice Address - Phone:616-738-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-14
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501300687225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist