Provider Demographics
NPI:1316416464
Name:GRANT, LEAH MARIES (LAC)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:MARIES
Last Name:GRANT
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4636 FOWLER AVE APT 73
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98203-2737
Mailing Address - Country:US
Mailing Address - Phone:714-914-8350
Mailing Address - Fax:
Practice Address - Street 1:7815 GREENWOOD AVE N
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103-4633
Practice Address - Country:US
Practice Address - Phone:206-706-7575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-19
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60897217171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist