Provider Demographics
NPI:1407500267
Name:GRANT, DYLAN ANTHONY (LMT)
Entity Type:Individual
Prefix:
First Name:DYLAN
Middle Name:ANTHONY
Last Name:GRANT
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 1:100 N WENATCHEE AVE
Mailing Address - Street 2:
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801-2239
Mailing Address - Country:US
Mailing Address - Phone:509-888-9989
Mailing Address - Fax:
Practice Address - Street 1:100 N WENATCHEE AVE
Practice Address - Street 2:
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801-2239
Practice Address - Country:US
Practice Address - Phone:509-888-9989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-09
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61254734225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist