Provider Demographics
NPI:1871357749
Name:GRISSOM, LADRA PEARL
Entity type:Individual
Prefix:
First Name:LADRA
Middle Name:PEARL
Last Name:GRISSOM
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 1:14207 103RD AVENUE CT E APT B303
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98374-3839
Mailing Address - Country:US
Mailing Address - Phone:206-638-9836
Mailing Address - Fax:
Practice Address - Street 1:6201 PACIFIC AVE STE C3
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98408-7423
Practice Address - Country:US
Practice Address - Phone:253-363-8853
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-12
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health