Provider Demographics
NPI:1306215835
Name:PANZELLA, GRANT (PT, DPT, ATC)
Entity Type:Individual
Prefix:MR
First Name:GRANT
Middle Name:
Last Name:PANZELLA
Suffix:
Gender:M
Credentials:PT, DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11917 LERWICK RD
Mailing Address - Street 2:
Mailing Address - City:CALEDONIA
Mailing Address - State:IL
Mailing Address - Zip Code:61011-9781
Mailing Address - Country:US
Mailing Address - Phone:815-914-6650
Mailing Address - Fax:
Practice Address - Street 1:11917 LERWICK RD
Practice Address - Street 2:
Practice Address - City:CALEDONIA
Practice Address - State:IL
Practice Address - Zip Code:61011-9781
Practice Address - Country:US
Practice Address - Phone:815-914-6650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-15
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X, 390200000X
IL070.026061225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program