Basic Information
Provider Information | |||||||||
NPI: | 1619113149 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GRANT | ||||||||
FirstName: | TERESA | ||||||||
MiddleName: | MAE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | OTR/L, CHT, LMT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 20 MITCHELL AVENUE | ||||||||
Address2: |   | ||||||||
City: | BINGHAMTON | ||||||||
State: | NY | ||||||||
PostalCode: | 13903 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6077622176 | ||||||||
FaxNumber: | 6077622002 | ||||||||
Practice Location | |||||||||
Address1: | 20 MITCHELL AVENUE | ||||||||
Address2: |   | ||||||||
City: | BINGHAMTON | ||||||||
State: | NY | ||||||||
PostalCode: | 13903 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6077622176 | ||||||||
FaxNumber: | 6077622002 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/06/2009 | ||||||||
LastUpdateDate: | 03/03/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | 012390 | NY | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |   | 225XH1200X | 004835-1 | NY | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Hand |
No ID Information.