Provider Demographics
NPI:1144592874
Name:GRANBERRY, RITA (LMT)
Entity Type:Individual
Prefix:MS
First Name:RITA
Middle Name:
Last Name:GRANBERRY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11700 ARROYO DE VIS NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-5748
Mailing Address - Country:US
Mailing Address - Phone:505-307-1447
Mailing Address - Fax:
Practice Address - Street 1:10701 LOMAS BLVD NE
Practice Address - Street 2:SUITE 111
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-5463
Practice Address - Country:US
Practice Address - Phone:505-307-1447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-26
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM7092225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist