Provider Demographics
NPI:1184887648
Name:GRISSETTE, FANSHAWE
Entity type:Individual
Prefix:MRS
First Name:FANSHAWE
Middle Name:
Last Name:GRISSETTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8611 NW 48TH ST
Mailing Address - Street 2:
Mailing Address - City:LAUDERHILL
Mailing Address - State:FL
Mailing Address - Zip Code:33351-5444
Mailing Address - Country:US
Mailing Address - Phone:954-651-4591
Mailing Address - Fax:
Practice Address - Street 1:8611 NW 48TH ST
Practice Address - Street 2:
Practice Address - City:LAUDERHILL
Practice Address - State:FL
Practice Address - Zip Code:33351-5444
Practice Address - Country:US
Practice Address - Phone:954-651-4591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-05
Last Update Date:2008-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist