MEDICARE: DANIELLE GRISCOM PT,DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	40QA01774200	NJ

General Provider Information

NPI Number	:	1093203309
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANIELLE GRISCOM PT,DPT

Provider Business Mailing Address
First Line	:	135 GEORGIA RD
Second Line	:
City	:	PENNSVILLE
State	:	NJ
Zip	:	08070-2450
Country	:	US
Telephone Number	:	856-275-1573
Fax Number	:

Provider Business Practice Location Address
First Line	:	118 OUTWATER LN
Second Line	:
City	:	GARFIELD
State	:	NJ
Zip	:	07026-2629
Country	:	US
Telephone Number	:	973-955-2190
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/23/2018
Last Update Date	:	04/23/2018

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