Provider Demographics
NPI:1790028892
Name:GRANT, REBECCA (LMT, NMT)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:GRANT
Suffix:
Gender:F
Credentials:LMT, NMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13316 MOUNTAIN RD NE
Mailing Address - Street 2:#1208
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-6196
Mailing Address - Country:US
Mailing Address - Phone:505-228-0787
Mailing Address - Fax:
Practice Address - Street 1:9720 CANDELARIA RD NE
Practice Address - Street 2:STE B
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-1457
Practice Address - Country:US
Practice Address - Phone:505-228-0787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-27
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3914225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist