Provider Demographics
NPI:1205241700
Name:GRANT, TAKIESA (LAC)
Entity type:Individual
Prefix:MS
First Name:TAKIESA
Middle Name:
Last Name:GRANT
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10645 GRAMERCY PL
Mailing Address - Street 2:#351
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-6073
Mailing Address - Country:US
Mailing Address - Phone:912-596-8911
Mailing Address - Fax:
Practice Address - Street 1:7750 MONTPELIER RD
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20723-6010
Practice Address - Country:US
Practice Address - Phone:912-596-8911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-24
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU02158171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist