Provider Demographics
NPI:1922506542
Name:GRANT, ROBERT
Entity Type:Individual
Prefix:
First Name:ROBERT
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 1:352 MARION AVE
Mailing Address - Street 2:
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-4014
Mailing Address - Country:US
Mailing Address - Phone:608-434-0081
Mailing Address - Fax:
Practice Address - Street 1:990 ELK GROVE TOWN CTR
Practice Address - Street 2:
Practice Address - City:ELK GROVE VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60007-3754
Practice Address - Country:US
Practice Address - Phone:847-290-1111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-29
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0043632255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer