Provider Demographics
NPI:1194156901
Name:GRENDE, ABBY
Entity type:Individual
Prefix:
First Name:ABBY
Middle Name:
Last Name:GRENDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2831 PANORAMA DR
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-1739
Mailing Address - Country:US
Mailing Address - Phone:701-269-1133
Mailing Address - Fax:
Practice Address - Street 1:2831 PANORAMA DR
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-1739
Practice Address - Country:US
Practice Address - Phone:701-269-1133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-03
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT-1218225X00000X
WAOT 60205352225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist