Provider Demographics
NPI:1538474242
Name:GRANT, AUDREY CAROLINE (MSOTR/L)
Entity Type:Individual
Prefix:MS
First Name:AUDREY
Middle Name:CAROLINE
Last Name:GRANT
Suffix:
Gender:F
Credentials:MSOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8104 SUNDOWN LN
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-2973
Mailing Address - Country:US
Mailing Address - Phone:240-446-1083
Mailing Address - Fax:
Practice Address - Street 1:1801 WENTWORTH RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21234-6128
Practice Address - Country:US
Practice Address - Phone:410-661-5717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-18
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD06547225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist