Provider Demographics
NPI:1689342594
Name:GRAND, LACY
Entity Type:Individual
Prefix:
First Name:LACY
Middle Name:
Last Name:GRAND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6397 LEE HWY
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-2564
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:BENCHMARK PHYSICAL THERAPY
Practice Address - Street 2:1820 HIGHWAY 20 STE 160
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-2076
Practice Address - Country:US
Practice Address - Phone:770-929-8872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-03
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT015489225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist