Provider Demographics
NPI:1306391610
Name:GRANT, CAMILLA
Entity Type:Individual
Prefix:
First Name:CAMILLA
Middle Name:
Last Name:GRANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46161 WESTLAKE DR
Mailing Address - Street 2:SUITE 330
Mailing Address - City:STERLING
Mailing Address - State:VA
Mailing Address - Zip Code:20165-5871
Mailing Address - Country:US
Mailing Address - Phone:703-444-9562
Mailing Address - Fax:703-430-2124
Practice Address - Street 1:46161 WESTLAKE DR
Practice Address - Street 2:SUITE 330
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20165-5871
Practice Address - Country:US
Practice Address - Phone:703-444-9562
Practice Address - Fax:703-430-2124
Is Sole Proprietor?:No
Enumeration Date:2016-08-17
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305207669225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist