Provider Demographics
NPI:1497776009
Name:GRISEL, JEREMY (PT)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:GRISEL
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 1:211 S TIMBERLAND DR
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75901-4065
Mailing Address - Country:US
Mailing Address - Phone:936-632-5511
Mailing Address - Fax:936-632-5633
Practice Address - Street 1:211 S TIMBERLAND DR
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75901-4065
Practice Address - Country:US
Practice Address - Phone:936-632-5511
Practice Address - Fax:936-632-5633
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTX1143659225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8T0598OtherBCBS PROVIDER NUMBER