Provider Demographics
NPI:1811373103
Name:GRANT, RICHARD II (PTA)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:GRANT
Suffix:II
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:895 PORTLAND RD
Mailing Address - Street 2:
Mailing Address - City:SACO
Mailing Address - State:ME
Mailing Address - Zip Code:04072-9673
Mailing Address - Country:US
Mailing Address - Phone:207-439-5104
Mailing Address - Fax:
Practice Address - Street 1:895 PORTLAND RD
Practice Address - Street 2:
Practice Address - City:SACO
Practice Address - State:ME
Practice Address - Zip Code:04072-9673
Practice Address - Country:US
Practice Address - Phone:207-439-5104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-10
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA4467225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant