Provider Demographics
NPI:1326177742
Name:GRANT, LISA ANN (PT, SCS, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:GRANT
Suffix:
Gender:F
Credentials:PT, SCS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4601 PARK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-2290
Mailing Address - Country:US
Mailing Address - Phone:704-323-3611
Mailing Address - Fax:
Practice Address - Street 1:15825 BALLANTYNE MEDICAL PL STE 120
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-4790
Practice Address - Country:US
Practice Address - Phone:704-323-3409
Practice Address - Fax:704-323-3982
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP15746225100000X
FLPT 235892251X0800X
SC56112251X0800X
SC9352255A2300X
FLAL17732255A2300X
NC15746225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer