Provider Demographics
NPI:1740522630
Name:GRIZZELL, DONNETA C (LMT)
Entity type:Individual
Prefix:
First Name:DONNETA
Middle Name:C
Last Name:GRIZZELL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:543 PALO VERDE WAY
Mailing Address - Street 2:
Mailing Address - City:CENTRAL POINT
Mailing Address - State:OR
Mailing Address - Zip Code:97502-1761
Mailing Address - Country:US
Mailing Address - Phone:541-621-4966
Mailing Address - Fax:
Practice Address - Street 1:245 E PINE ST
Practice Address - Street 2:
Practice Address - City:CENTRAL POINT
Practice Address - State:OR
Practice Address - Zip Code:97502-2251
Practice Address - Country:US
Practice Address - Phone:541-621-4966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-19
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR18453OtherLICENSED MASSAGE THERAPIST