Provider Demographics
NPI:1528588100
Name:GRANBERRY, KAREN SUE (PT)
Entity Type:Individual
Prefix:MRS
First Name:KAREN
Middle Name:SUE
Last Name:GRANBERRY
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 1:2816 RAYMOND AVE
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-3214
Mailing Address - Country:US
Mailing Address - Phone:406-214-9625
Mailing Address - Fax:
Practice Address - Street 1:3018 RATTLESNAKE DR
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-6101
Practice Address - Country:US
Practice Address - Phone:406-549-0988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-23
Last Update Date:2017-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPTP-PT-LIC-426225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist