Provider Demographics
NPI:1841167483
Name:MANGAN, GRANT
Entity type:Individual
Prefix:
First Name:GRANT
Middle Name:
Last Name:MANGAN
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 1:578 HIGHLAND RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-2703
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 CHESTERFIELD CTR STE 300
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-4823
Practice Address - Country:US
Practice Address - Phone:636-778-9643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-20
Last Update Date:2025-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2025045402225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant