Provider Demographics
NPI:1366074932
Name:GRISSOM, TYESHA (PT, DPT)
Entity type:Individual
Prefix:
First Name:TYESHA
Middle Name:
Last Name:GRISSOM
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8848 GREENVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-7143
Mailing Address - Country:US
Mailing Address - Phone:877-293-6287
Mailing Address - Fax:
Practice Address - Street 1:8848 GREENVILLE AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-7143
Practice Address - Country:US
Practice Address - Phone:877-293-6287
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-11
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1196223225100000X
GAPT009052225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist