Provider Demographics
NPI:1912958737
Name:GRIZZLE, KENNETH L (PHD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:L
Last Name:GRIZZLE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13800 W NORTH AVE
Mailing Address - Street 2:CHILD DEVELOPMENT CENTER OF CHW
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-4977
Mailing Address - Country:US
Mailing Address - Phone:262-432-6600
Mailing Address - Fax:262-432-6604
Practice Address - Street 1:13800 W NORTH AVE
Practice Address - Street 2:CHILD DEVELOPMENT CENTER OF CHW
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-4977
Practice Address - Country:US
Practice Address - Phone:262-432-6600
Practice Address - Fax:262-432-6604
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2013-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2187103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
005000215GOtherHUMANA
WI1912958737Medicaid
WI1912958737Medicaid
WI73601 1987Medicare PIN
WI68086 0733Medicare PIN
WI60255 0087Medicare PIN