Provider Demographics
NPI:1740774884
Name:GRANT, GENEVIEVE ANNE (PTA)
Entity Type:Individual
Prefix:
First Name:GENEVIEVE
Middle Name:ANNE
Last Name:GRANT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4825 CEDAR DR
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-4954
Mailing Address - Country:US
Mailing Address - Phone:515-480-6473
Mailing Address - Fax:
Practice Address - Street 1:4825 CEDAR DR
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-4954
Practice Address - Country:US
Practice Address - Phone:515-480-6473
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-21
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00457225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant