Provider Demographics
NPI:1790909778
Name:GRIMSLEY, KRISTI L (PT)
Entity type:Individual
Prefix:
First Name:KRISTI
Middle Name:L
Last Name:GRIMSLEY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 MEDICAL DR STE B
Mailing Address - Street 2:
Mailing Address - City:PALESTINE
Mailing Address - State:TX
Mailing Address - Zip Code:75801-8508
Mailing Address - Country:US
Mailing Address - Phone:903-723-3602
Mailing Address - Fax:936-633-5695
Practice Address - Street 1:123 MEDICAL DR STE B
Practice Address - Street 2:
Practice Address - City:PALESTINE
Practice Address - State:TX
Practice Address - Zip Code:75801-8508
Practice Address - Country:US
Practice Address - Phone:903-723-3602
Practice Address - Fax:903-731-9573
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10990752251P0200X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX83392TOtherBLUE CROSS BLUE SHIELD
TX108015202Medicaid