Provider Demographics
NPI:1669863411
Name:HILLESTAD, GRANT (OTR/L)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:
Last Name:HILLESTAD
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:674 EASTLAND DR
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-6846
Mailing Address - Country:US
Mailing Address - Phone:208-734-4264
Mailing Address - Fax:
Practice Address - Street 1:674 EASTLAND DR
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-6846
Practice Address - Country:US
Practice Address - Phone:208-734-4264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-16
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA077135225X00000X
IDOT-1629225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist