Provider Demographics
NPI:1467548974
Name:GRINSTEAD, STEPHANIE JO
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:JO
Last Name:GRINSTEAD
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 1:1712 HOLTON ROAD
Mailing Address - Street 2:SUITE B
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49445
Mailing Address - Country:US
Mailing Address - Phone:231-719-1921
Mailing Address - Fax:231-719-9470
Practice Address - Street 1:1712 HOLTON ROAD
Practice Address - Street 2:SUITE B
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49445
Practice Address - Country:US
Practice Address - Phone:231-719-1921
Practice Address - Fax:231-719-9470
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIDIPLOMA ONLY225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI30609OtherBCBS
MI4717630Medicaid
MI30609OtherBCBS