Basic Information
| Provider Information | |||||||||
| NPI: | 1346773413 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRIESENAUER | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | EDWARD | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 608 NORRIS AVE | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372043708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6156951455 | ||||||||
| FaxNumber: | 6156951483 | ||||||||
| Practice Location | |||||||||
| Address1: | 141 HILLCREST DR | ||||||||
| Address2: | |||||||||
| City: | CLARKSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9315524340 | ||||||||
| FaxNumber: | 9315520999 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2017 | ||||||||
| LastUpdateDate: | 09/05/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 11455 | TN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | Q035204 | 05 | TN | MEDICAID |