Provider Demographics
NPI:1710929666
Name:GRANAHAN, KENNETH M (MPT)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:M
Last Name:GRANAHAN
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 WELLES ST
Mailing Address - Street 2:SUITE 166
Mailing Address - City:FORTY FORT
Mailing Address - State:PA
Mailing Address - Zip Code:18704-4968
Mailing Address - Country:US
Mailing Address - Phone:570-714-4171
Mailing Address - Fax:570-714-4188
Practice Address - Street 1:190 WELLES ST
Practice Address - Street 2:SUITE 166
Practice Address - City:FORTY FORT
Practice Address - State:PA
Practice Address - Zip Code:18704-4968
Practice Address - Country:US
Practice Address - Phone:570-714-4171
Practice Address - Fax:570-714-4188
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT018090225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist