Provider Demographics
NPI:1467493031
Name:WILSON, GRANT III (MS, ATC, LAT)
Entity Type:Individual
Prefix:MR
First Name:GRANT
Middle Name:
Last Name:WILSON
Suffix:III
Gender:M
Credentials:MS, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 801
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VT
Mailing Address - Zip Code:05477-0801
Mailing Address - Country:US
Mailing Address - Phone:802-310-1790
Mailing Address - Fax:
Practice Address - Street 1:140 PATRICK GYM 97 SPEAR ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05405-0001
Practice Address - Country:US
Practice Address - Phone:802-656-9951
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer