Provider Demographics
NPI:1245583244
Name:GRANT, ROBERT KELLY (LMP, NCTMB)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:KELLY
Last Name:GRANT
Suffix:
Gender:M
Credentials:LMP, NCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1836 WESTLAKE AVE N
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98109-2755
Mailing Address - Country:US
Mailing Address - Phone:206-914-0288
Mailing Address - Fax:
Practice Address - Street 1:1836 WESTLAKE AVE N
Practice Address - Street 2:SUITE 102
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98109-2755
Practice Address - Country:US
Practice Address - Phone:206-914-0288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-16
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 00017889172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA 00017889OtherMASSAGE PRACTITIONER LICENSE
WA387113-00OtherNCBTMB CERTIFICATION NUMBER