Provider Demographics
NPI:1245390640
Name:GRANT, KENYON ELIZABETH (PT)
Entity Type:Individual
Prefix:MRS
First Name:KENYON
Middle Name:ELIZABETH
Last Name:GRANT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:KENYON
Other - Middle Name:ELIZABETH
Other - Last Name:KRAUSE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:1 PETERS CANYON RD STE 120
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92606-1748
Mailing Address - Country:US
Mailing Address - Phone:949-679-3988
Mailing Address - Fax:562-431-9854
Practice Address - Street 1:25285 MADISON AVE STE 102
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-8955
Practice Address - Country:US
Practice Address - Phone:951-600-0054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT24443225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT24443OtherPT LICENSE
CAES075ZMedicare PIN