Healthcare Provider Details

I. General information

NPI: 1356881312
Provider Name (Legal Business Name): LAUREN GRYNIEWICZ P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2017
Last Update Date: 02/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N MAYFAIR RD SUITE 550
WAUWATOSA WI
53226-1409
US

IV. Provider business mailing address

2500 N MAYFAIR RD SUITE 500
WAUWATOSA WI
53226-1409
US

V. Phone/Fax

Practice location:
  • Phone: 414-443-1269
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number13088-24
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: