Provider Demographics
NPI:1114649043
Name:MUSSETTER, GRACE DOUGHERTY (DPT)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:DOUGHERTY
Last Name:MUSSETTER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:GRACE
Other - Middle Name:ANNE
Other - Last Name:DOUGHERTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:530 FAIRFIELD DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40206-2932
Mailing Address - Country:US
Mailing Address - Phone:502-415-0446
Mailing Address - Fax:
Practice Address - Street 1:530 FAIRFIELD DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40206-2932
Practice Address - Country:US
Practice Address - Phone:502-415-0446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-16
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY008574225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist