Healthcare Provider Details

I. General information

NPI: 1255171633
Provider Name (Legal Business Name): SAMARA GRISSOM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2024
Last Update Date: 05/31/2024
Certification Date: 05/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4070 25TH ST
COLUMBUS IN
47203-3161
US

IV. Provider business mailing address

1019 FRANKLIN ST APT 1
COLUMBUS IN
47201-5786
US

V. Phone/Fax

Practice location:
  • Phone: 812-373-6103
  • Fax: 888-375-4149
Mailing address:
  • Phone: 812-341-7615
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-21-188553
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: