Provider Demographics
NPI:1609341346
Name:GRANT, REBECCA (OT)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:GRANT
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:
Other - Last Name:RISLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:20 PEACHTREE CT STE 105
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-4616
Mailing Address - Country:US
Mailing Address - Phone:631-467-3700
Mailing Address - Fax:631-467-0928
Practice Address - Street 1:5 S FAMILY DR
Practice Address - Street 2:
Practice Address - City:COLONIE
Practice Address - State:NY
Practice Address - Zip Code:12205-1049
Practice Address - Country:US
Practice Address - Phone:518-728-6431
Practice Address - Fax:518-235-5458
Is Sole Proprietor?:No
Enumeration Date:2018-10-09
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010421225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist