Provider Demographics
NPI:1154686897
Name:HASENOUR, GRANT J (OT)
Entity type:Individual
Prefix:
First Name:GRANT
Middle Name:J
Last Name:HASENOUR
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7300 E INDIANA ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47715-2794
Mailing Address - Country:US
Mailing Address - Phone:812-476-0409
Mailing Address - Fax:812-476-1016
Practice Address - Street 1:225 CROSSLAKE DR
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-8198
Practice Address - Country:US
Practice Address - Phone:812-477-1558
Practice Address - Fax:812-474-2296
Is Sole Proprietor?:No
Enumeration Date:2012-07-09
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31005321A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201121040Medicaid
IN000000778985OtherBLUE CROSS BLUE SHIELD
IN000000779303OtherBLUE CROSS BLUE SHIELD
IN000000779590OtherBLUE CROSS BLUE SHIELD
IN198850007Medicare PIN
IN000000778985OtherBLUE CROSS BLUE SHIELD
IN000000779590OtherBLUE CROSS BLUE SHIELD