Provider Demographics
NPI:1720825599
Name:GRIZENKO, NATHAN LUCAS (OTD, OTR/L)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:LUCAS
Last Name:GRIZENKO
Suffix:
Gender:M
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 OLENTANGY ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-2342
Mailing Address - Country:US
Mailing Address - Phone:740-274-2996
Mailing Address - Fax:
Practice Address - Street 1:5700 BLAZER PKWY
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43017-3665
Practice Address - Country:US
Practice Address - Phone:614-962-8330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-10
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOT012597225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist