Healthcare Provider Details

I. General information

NPI: 1922467802
Provider Name (Legal Business Name): RACHEL HANNUM-GRINSTEAD D.P.T., A.T.C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2016
Last Update Date: 02/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CMR 402
APO AE
09180
US

IV. Provider business mailing address

PSC 2 BOX 15675
APO AE
09012-0157
US

V. Phone/Fax

Practice location:
  • Phone: 314-590-7298
  • Fax:
Mailing address:
  • Phone: 015166057884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number4558
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2000005401
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: