Provider Demographics
NPI:1629446687
Name:GRISELL, KEVIN STEPHEN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:STEPHEN
Last Name:GRISELL
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12705 SE RIVER RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-9799
Mailing Address - Country:US
Mailing Address - Phone:503-654-6581
Mailing Address - Fax:
Practice Address - Street 1:12705 SE RIVER RD
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-9799
Practice Address - Country:US
Practice Address - Phone:503-654-6581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-08
Last Update Date:2015-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR61387225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist