Provider Demographics
NPI:1770974644
Name:GRASS, THERESA
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:GRASS
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:PO BOX 1832
Mailing Address - Street 2:
Mailing Address - City:PITTSBURG
Mailing Address - State:KS
Mailing Address - Zip Code:66762-1832
Mailing Address - Country:US
Mailing Address - Phone:620-231-9873
Mailing Address - Fax:
Practice Address - Street 1:3011 N MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:PITTSBURG
Practice Address - State:KS
Practice Address - Zip Code:66762-2546
Practice Address - Country:US
Practice Address - Phone:620-231-9873
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-12
Last Update Date:2025-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2657103TC1900X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100240930AMedicaid