Provider Demographics
NPI:1871722819
Name:RICKER, STEPHANIE GRINDSTAFF (BS)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:GRINDSTAFF
Last Name:RICKER
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:GRINDSTAFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BS
Mailing Address - Street 1:109 W WATAUGA AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-5621
Mailing Address - Country:US
Mailing Address - Phone:423-232-2600
Mailing Address - Fax:
Practice Address - Street 1:109 W WATAUGA AVE
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-5621
Practice Address - Country:US
Practice Address - Phone:423-232-2600
Practice Address - Fax:423-467-3644
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-13
Last Update Date:2009-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator