Provider Demographics
NPI:1346092194
Name:MACERI, GRANT (LMT)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:
Last Name:MACERI
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6809 MOORES FERRY DR
Mailing Address - Street 2:
Mailing Address - City:DEL VALLE
Mailing Address - State:TX
Mailing Address - Zip Code:78617-3746
Mailing Address - Country:US
Mailing Address - Phone:949-370-1561
Mailing Address - Fax:
Practice Address - Street 1:704 HIGHWAY 71 W STE D200
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:TX
Practice Address - Zip Code:78602-4144
Practice Address - Country:US
Practice Address - Phone:949-370-1561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-04
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT127206225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist