Provider Demographics
NPI:1750698510
Name:GRANT, PATRICIA ELAINE (LMT/MMP)
Entity type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:ELAINE
Last Name:GRANT
Suffix:
Gender:F
Credentials:LMT/MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 MANOR DR
Mailing Address - Street 2:
Mailing Address - City:PONCHATOULA
Mailing Address - State:LA
Mailing Address - Zip Code:70454-2920
Mailing Address - Country:US
Mailing Address - Phone:985-507-7319
Mailing Address - Fax:
Practice Address - Street 1:120 MANOR DR
Practice Address - Street 2:
Practice Address - City:PONCHATOULA
Practice Address - State:LA
Practice Address - Zip Code:70454-2920
Practice Address - Country:US
Practice Address - Phone:985-507-7319
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-31
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALA # 1476225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist