Provider Demographics
NPI:1770822355
Name:GRANSBERRY, AUTUMN (LMT)
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:
Last Name:GRANSBERRY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4024 N 98TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53222-1421
Mailing Address - Country:US
Mailing Address - Phone:414-336-0683
Mailing Address - Fax:
Practice Address - Street 1:15720 W NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-5119
Practice Address - Country:US
Practice Address - Phone:262-785-5515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-02
Last Update Date:2013-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11942-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist