Provider Demographics
NPI:1619113149
Name:GRANT, TERESA MAE (OTR/L, CHT, LMT)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:MAE
Last Name:GRANT
Suffix:
Gender:F
Credentials:OTR/L, CHT, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 MITCHELL AVENUE
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13903
Mailing Address - Country:US
Mailing Address - Phone:607-762-2176
Mailing Address - Fax:607-762-2002
Practice Address - Street 1:20 MITCHELL AVENUE
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13903
Practice Address - Country:US
Practice Address - Phone:607-762-2176
Practice Address - Fax:607-762-2002
Is Sole Proprietor?:No
Enumeration Date:2009-01-06
Last Update Date:2009-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012390225700000X
NY004835-1225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist