Provider Demographics
NPI:1154568590
Name:GRAMBOW, THORSTEN (LMT, CMT)
Entity type:Individual
Prefix:
First Name:THORSTEN
Middle Name:
Last Name:GRAMBOW
Suffix:
Gender:M
Credentials:LMT, CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2015 OLYMPIC BLVD
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94595-1621
Mailing Address - Country:US
Mailing Address - Phone:207-649-3088
Mailing Address - Fax:
Practice Address - Street 1:1200 MT DIABLO BLVD
Practice Address - Street 2:SUITE # 103
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94596-4852
Practice Address - Country:US
Practice Address - Phone:207-649-3088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-07
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39084225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist