Provider Demographics
NPI:1275598567
Name:GRANT, ANGELA (LMP)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:GRANT
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5210 CORPORATE CENTER LOOP SE
Mailing Address - Street 2:SUITE D
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-5952
Mailing Address - Country:US
Mailing Address - Phone:360-455-8155
Mailing Address - Fax:360-455-1655
Practice Address - Street 1:111 MARKET ST NE
Practice Address - Street 2:SUITE 108
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98501-1008
Practice Address - Country:US
Practice Address - Phone:360-754-7085
Practice Address - Fax:360-754-3671
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2009-01-16
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA3456GROtherREGENCE BLUESHIELD
WA8903856OtherL & I CRIME VICTIMS
WA0149551OtherDEPT. OF LABOR & INDUSTRY
WA7174664OtherAETNA