Provider Demographics
NPI:1780192617
Name:GRIZZLE, DAKOTA A
Entity Type:Individual
Prefix:
First Name:DAKOTA
Middle Name:A
Last Name:GRIZZLE
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 1:3101 MAGIC HOLLOW BLVD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23453-3010
Mailing Address - Country:US
Mailing Address - Phone:757-639-2218
Mailing Address - Fax:
Practice Address - Street 1:3101 MAGIC HOLLOW BLVD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23453
Practice Address - Country:US
Practice Address - Phone:757-639-2218
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-12
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0133002160103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst