Provider Demographics
NPI:1750440087
Name:GRANT, GARRY ANDREW (MS, ATC, CSCS)
Entity type:Individual
Prefix:
First Name:GARRY
Middle Name:ANDREW
Last Name:GRANT
Suffix:
Gender:M
Credentials:MS, ATC, CSCS
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Other - Middle Name:
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Mailing Address - Street 1:3477 SOUTHRIDGE COURT
Mailing Address - Street 2:#2
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701
Mailing Address - Country:US
Mailing Address - Phone:715-836-3877
Mailing Address - Fax:715-836-5152
Practice Address - Street 1:105 GARFIELD AVE
Practice Address - Street 2:MCPHEE PHYSICAL EDUCATION CENTER
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-4811
Practice Address - Country:US
Practice Address - Phone:715-836-3877
Practice Address - Fax:715-836-5152
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI728-0392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer