Provider Demographics
NPI:1457088106
Name:GRISSOM, KENRODRIC
Entity type:Individual
Prefix:
First Name:KENRODRIC
Middle Name:
Last Name:GRISSOM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12725 33RD AVE NE APT B501
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98125-8908
Mailing Address - Country:US
Mailing Address - Phone:206-849-0614
Mailing Address - Fax:
Practice Address - Street 1:100 23RD AVE S
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98144-2302
Practice Address - Country:US
Practice Address - Phone:206-849-0614
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-03
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor