Basic Information
| Provider Information | |||||||||
| NPI: | 1912367087 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRIGSBY | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | VERNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MA, RN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GRIGSBY | ||||||||
| OtherFirstName: | MICHAEL | ||||||||
| OtherMiddleName: | VERNE | ||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MA, RN | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4002 W QUINN PL | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802363523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033242432 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1290 S POTOMAC ST | ||||||||
| Address2: | |||||||||
| City: | AURORA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800124524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037451281 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2016 | ||||||||
| LastUpdateDate: | 03/02/2016 | ||||||||
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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 | 163WP0807X | 1619787 | CO | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health, Child & Adolescent |
ID Information
| ID | Type | State | Issuer | Description | 163WP0807X | 01 | CO | NPI | OTHER |