Provider Demographics
NPI:1790183556
Name:GRANT, STEPHEN
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:GRANT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41125 N DAISY MOUNTAIN DR
Mailing Address - Street 2:SUITE 125
Mailing Address - City:ANTHEM
Mailing Address - State:AZ
Mailing Address - Zip Code:85086-4954
Mailing Address - Country:US
Mailing Address - Phone:623-551-9706
Mailing Address - Fax:623-551-5078
Practice Address - Street 1:41125 N DAISY MOUNTAIN DR
Practice Address - Street 2:SUITE 121
Practice Address - City:ANTHEM
Practice Address - State:AZ
Practice Address - Zip Code:85086-4954
Practice Address - Country:US
Practice Address - Phone:623-551-9706
Practice Address - Fax:623-551-9708
Is Sole Proprietor?:No
Enumeration Date:2014-12-10
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9680225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ976472Medicaid
AZZ172945Medicare PIN