Provider Demographics
NPI:1710574173
Name:GRANT, ALICA
Entity Type:Individual
Prefix:
First Name:ALICA
Middle Name:
Last Name:GRANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALICA
Other - Middle Name:
Other - Last Name:DELGADO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2200 NE PROFESSIONAL CT
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-6063
Mailing Address - Country:US
Mailing Address - Phone:541-389-6313
Mailing Address - Fax:541-389-8760
Practice Address - Street 1:2200 NE PROFESSIONAL CT
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-6063
Practice Address - Country:US
Practice Address - Phone:541-389-6313
Practice Address - Fax:541-389-8760
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-30
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR171R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171R00000XOther Service ProvidersInterpreterGroup - Single Specialty