Provider Demographics
NPI:1891988804
Name:GRISMER, KELLI DAWN (PTA)
Entity Type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:DAWN
Last Name:GRISMER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 2ND ST NE
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:SD
Mailing Address - Zip Code:57201-2512
Mailing Address - Country:US
Mailing Address - Phone:605-882-3724
Mailing Address - Fax:
Practice Address - Street 1:215 2ND ST NE
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201-2512
Practice Address - Country:US
Practice Address - Phone:605-882-3724
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-22
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0169225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant