Provider Demographics
NPI:1538488390
Name:GRANT, ROBERTA MARINA (LMT)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:MARINA
Last Name:GRANT
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 WEST STEUBEN
Mailing Address - Street 2:
Mailing Address - City:BINGEN
Mailing Address - State:WA
Mailing Address - Zip Code:98605-0000
Mailing Address - Country:US
Mailing Address - Phone:541-490-9794
Mailing Address - Fax:
Practice Address - Street 1:208 WEST STEUBEN
Practice Address - Street 2:
Practice Address - City:BINGEN
Practice Address - State:WA
Practice Address - Zip Code:98605-0000
Practice Address - Country:US
Practice Address - Phone:541-490-9794
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-19
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 00020199225700000X
OR10856225700000X
WA60836397101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist