Provider Demographics
NPI:1912654922
Name:GRIGG, DAVID JOSEPH
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:JOSEPH
Last Name:GRIGG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14151 GEORGIAN CIR APT 207
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-5620
Mailing Address - Country:US
Mailing Address - Phone:239-738-9244
Mailing Address - Fax:
Practice Address - Street 1:3400 SW 17TH PL FL 33914
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33914-4919
Practice Address - Country:US
Practice Address - Phone:239-549-2726
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-09
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-21-190425106S00000X
106S00000X
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician