Provider Demographics
NPI:1497489116
Name:GRANDINETTI, MARK TAYLOR (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:TAYLOR
Last Name:GRANDINETTI
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 LYNDON FARM CT STE 300
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5005
Mailing Address - Country:US
Mailing Address - Phone:856-677-4000
Mailing Address - Fax:856-234-3014
Practice Address - Street 1:1011 W PENN AVE
Practice Address - Street 2:
Practice Address - City:ROBESONIA
Practice Address - State:PA
Practice Address - Zip Code:19551-9550
Practice Address - Country:US
Practice Address - Phone:610-589-2263
Practice Address - Fax:610-589-2232
Is Sole Proprietor?:No
Enumeration Date:2022-07-11
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT030591225100000X
PATPT023609225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist