Provider Demographics
NPI:1629236468
Name:GRANT, CARRIE ANN (MPT)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:ANN
Last Name:GRANT
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:423 SCRANTON CARBONDALE HWY
Mailing Address - Street 2:S
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18508-1115
Mailing Address - Country:US
Mailing Address - Phone:570-207-5502
Mailing Address - Fax:570-207-5511
Practice Address - Street 1:423 SCRANTON CARBONDALE HWY
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18508-1115
Practice Address - Country:US
Practice Address - Phone:570-207-5502
Practice Address - Fax:570-207-5511
Is Sole Proprietor?:No
Enumeration Date:2008-05-29
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATPT020602225100000X
2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA002056184OtherBS
PA102261054OtherMEDICAL ASSISTANCE
PA002056184OtherBS