Provider Demographics
NPI:1104028976
Name:GRUSHKOVSKIY, MIKHAIL (MT)
Entity type:Individual
Prefix:
First Name:MIKHAIL
Middle Name:
Last Name:GRUSHKOVSKIY
Suffix:
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:875 140TH AVE NE
Mailing Address - Street 2:STE 202
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98005-3400
Mailing Address - Country:US
Mailing Address - Phone:425-462-6604
Mailing Address - Fax:425-452-3292
Practice Address - Street 1:875 140TH AVE NE
Practice Address - Street 2:STE 202
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98005-3400
Practice Address - Country:US
Practice Address - Phone:425-462-6604
Practice Address - Fax:425-452-3292
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00009482225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist