Provider Demographics
NPI:1740911429
Name:GRANDT, CHARLES (PT, DPT)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:
Last Name:GRANDT
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6744 ROANOAKE CT
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-4011
Mailing Address - Country:US
Mailing Address - Phone:847-650-1927
Mailing Address - Fax:
Practice Address - Street 1:2151 WAUKEGAN RD
Practice Address - Street 2:STE 130
Practice Address - City:BANNOCKBURN
Practice Address - State:IL
Practice Address - Zip Code:60015-1868
Practice Address - Country:US
Practice Address - Phone:847-444-1321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-22
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070025959225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist