Provider Demographics
NPI:1659855724
Name:GRYSZOWKA, CHRISTIAN (OTD, MS, OTR/L, CHT)
Entity Type:Individual
Prefix:DR
First Name:CHRISTIAN
Middle Name:
Last Name:GRYSZOWKA
Suffix:
Gender:M
Credentials:OTD, MS, OTR/L, CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11050 MOUNT BELVEDERE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT DRUM
Mailing Address - State:NY
Mailing Address - Zip Code:13602-5438
Mailing Address - Country:US
Mailing Address - Phone:315-772-6652
Mailing Address - Fax:
Practice Address - Street 1:11050 MOUNT BELVEDERE BLVD
Practice Address - Street 2:
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602-5438
Practice Address - Country:US
Practice Address - Phone:315-772-6652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-24
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY245206225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100567050Medicaid