Provider Demographics
NPI:1114589272
Name:GRANT, JANIE (OT)
Entity Type:Individual
Prefix:
First Name:JANIE
Middle Name:
Last Name:GRANT
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 NORTH AVE UNIT 102
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-5557
Mailing Address - Country:US
Mailing Address - Phone:818-640-3359
Mailing Address - Fax:
Practice Address - Street 1:500 TAMAL PLZ STE 525&527
Practice Address - Street 2:
Practice Address - City:CORTE MADERA
Practice Address - State:CA
Practice Address - Zip Code:94925-1151
Practice Address - Country:US
Practice Address - Phone:415-531-3027
Practice Address - Fax:941-655-8839
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-28
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19097225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA19097OtherOCCUPATIONAL THERAPIST LICENSE