Healthcare Provider Details

I. General information

NPI: 1750606794
Provider Name (Legal Business Name): MARY LYNN GRIZZELL LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2010
Last Update Date: 04/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 S COLLEGE AVE STE 101
COLLEGE PLACE WA
99324-1193
US

IV. Provider business mailing address

2928 DETOUR RD
WALLA WALLA WA
99362-7278
US

V. Phone/Fax

Practice location:
  • Phone: 509-527-2425
  • Fax: 509-527-2426
Mailing address:
  • Phone: 509-386-5325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA60095108
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: