MEDICARE: MR. KENNETH GRIDER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1588317762
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KENNETH GRIDER

Provider Business Mailing Address
First Line	:	1467 S VAN DYKE WAY
Second Line	:
City	:	LAKEWOOD
State	:	CO
Zip	:	80228-3916
Country	:	US
Telephone Number	:	720-201-8863
Fax Number	:

Provider Business Practice Location Address
First Line	:	1467 S VAN DYKE WAY
Second Line	:
City	:	LAKEWOOD
State	:	CO
Zip	:	80228-3916
Country	:	US
Telephone Number	:	720-201-8863
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/28/2022
Last Update Date	:	01/28/2022

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