Provider Demographics
NPI:1780852889
Name:GRISE, MICHAEL D (LMT, EST)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:GRISE
Suffix:
Gender:M
Credentials:LMT, EST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4044 FORT CAMPBELL BLVD
Mailing Address - Street 2:PMB 124
Mailing Address - City:HOPKINSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42240-4950
Mailing Address - Country:US
Mailing Address - Phone:270-305-1817
Mailing Address - Fax:
Practice Address - Street 1:1202 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:HOPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42240-4937
Practice Address - Country:US
Practice Address - Phone:270-881-1005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-12
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY0195225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist