Provider Demographics
NPI:1053967083
Name:GRISSETT, SEAN DARRIEUS
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:DARRIEUS
Last Name:GRISSETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 N BAILEY ST
Mailing Address - Street 2:
Mailing Address - City:PRYOR
Mailing Address - State:OK
Mailing Address - Zip Code:74361-4201
Mailing Address - Country:US
Mailing Address - Phone:918-824-7770
Mailing Address - Fax:
Practice Address - Street 1:111 N BAILEY ST
Practice Address - Street 2:
Practice Address - City:PRYOR
Practice Address - State:OK
Practice Address - Zip Code:74361-4201
Practice Address - Country:US
Practice Address - Phone:918-824-7770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-15
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK700225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant