Provider Demographics
NPI:1407356256
Name:GRAMBO, JANE FAHLGREN (PT)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:FAHLGREN
Last Name:GRAMBO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17150 WATERLOO ST STE 150
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48230-1201
Mailing Address - Country:US
Mailing Address - Phone:313-473-4700
Mailing Address - Fax:
Practice Address - Street 1:17150 WATERLOO ST
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE
Practice Address - State:MI
Practice Address - Zip Code:48230-1201
Practice Address - Country:US
Practice Address - Phone:313-473-4700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-19
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI55010022352251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic