Provider Demographics
NPI:1265239826
Name:GROSSO, MIKAILA (LMT)
Entity type:Individual
Prefix:
First Name:MIKAILA
Middle Name:
Last Name:GROSSO
Suffix:
Gender:
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:427 PERCIVAL ST NW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-4855
Mailing Address - Country:US
Mailing Address - Phone:360-878-0400
Mailing Address - Fax:
Practice Address - Street 1:405 BLACK HILLS LN SW STE D2
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-8661
Practice Address - Country:US
Practice Address - Phone:425-202-5210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-28
Last Update Date:2025-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61647811225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist