Provider Demographics
NPI:1558145094
Name:KIRSCHBAUM, GRANT P (PTA)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:P
Last Name:KIRSCHBAUM
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1041 SW REDBUCK CIR
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64081-3867
Mailing Address - Country:US
Mailing Address - Phone:816-729-8038
Mailing Address - Fax:
Practice Address - Street 1:111 NE MOCK AVE
Practice Address - Street 2:
Practice Address - City:BLUE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64014-2503
Practice Address - Country:US
Practice Address - Phone:816-729-8038
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-24
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023032658225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty