Provider Demographics
NPI:1689090920
Name:GRISSOM, CARTER LANE
Entity Type:Individual
Prefix:MR
First Name:CARTER
Middle Name:LANE
Last Name:GRISSOM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:776 SO. STATE ST.
Mailing Address - Street 2:SUITE 107
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482
Mailing Address - Country:US
Mailing Address - Phone:707-463-4915
Mailing Address - Fax:707-463-4917
Practice Address - Street 1:776 SO. STATE ST.
Practice Address - Street 2:SUITE 107
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482
Practice Address - Country:US
Practice Address - Phone:707-463-4915
Practice Address - Fax:707-463-4917
Is Sole Proprietor?:No
Enumeration Date:2014-03-11
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator