Provider Demographics
NPI:1588041404
Name:GRANT, TIFFANI M (MOT, OTR)
Entity Type:Individual
Prefix:
First Name:TIFFANI
Middle Name:M
Last Name:GRANT
Suffix:
Gender:F
Credentials:MOT, OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3703 W LAKE AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60026-1223
Mailing Address - Country:US
Mailing Address - Phone:847-998-1188
Mailing Address - Fax:
Practice Address - Street 1:3703 W LAKE AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026-1223
Practice Address - Country:US
Practice Address - Phone:847-998-1188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-29
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.011004225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist