Provider Demographics
NPI:1255791505
Name:GRANT, TINA (LMP)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:GRANT
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19810 BAGLEY DR N APT U302
Mailing Address - Street 2:
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98133-2786
Mailing Address - Country:US
Mailing Address - Phone:510-552-8885
Mailing Address - Fax:
Practice Address - Street 1:19810 BAGLEY DR N APT U302
Practice Address - Street 2:
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98133-2786
Practice Address - Country:US
Practice Address - Phone:510-552-8885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-29
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60433854225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist