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General NPI Number Information
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NPI Number | 1770822355
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Entity Type | Individual
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Provider Name | AUTUMN GRANSBERRY LMT
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Gender | Female
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Dates
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Enumeration Date | 02/02/2013
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Last Update Date | 02/02/2013
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Provider Practice Location Address
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Address Line | 15720 W NATIONAL AVE
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City | NEW BERLIN
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State | WI
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Zip | 53151-5119
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Country | US
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Telephone | 262-785-5515
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Fax |
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Provider Business Mailing Address
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Address Line | 4024 N 98TH ST
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City | MILWAUKEE
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State | WI
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Zip | 53222-1421
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Country | US
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Telephone | 414-336-0683
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 11942-146
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License Number State | WI
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