Provider Demographics
NPI:1740649854
Name:GRIVEJ, KRISTYN
Entity type:Individual
Prefix:
First Name:KRISTYN
Middle Name:
Last Name:GRIVEJ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRISTYN
Other - Middle Name:
Other - Last Name:FORTAIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:2700 ORCHARD LAKE RD
Practice Address - Street 2:
Practice Address - City:KEEGO HARBOR
Practice Address - State:MI
Practice Address - Zip Code:48320-1445
Practice Address - Country:US
Practice Address - Phone:248-683-0185
Practice Address - Fax:248-683-5692
Is Sole Proprietor?:No
Enumeration Date:2016-02-17
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501017603225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist