Provider Demographics
NPI:1912451584
Name:GRANT, TAKIYA E (DPT)
Entity Type:Individual
Prefix:
First Name:TAKIYA
Middle Name:E
Last Name:GRANT
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 COWLES CLINC WAY
Mailing Address - Street 2:D-100
Mailing Address - City:GREENSBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30642-5285
Mailing Address - Country:US
Mailing Address - Phone:706-454-1394
Mailing Address - Fax:706-454-1397
Practice Address - Street 1:1000 COWLES CLINC WAY
Practice Address - Street 2:D-100
Practice Address - City:GREENSBORO
Practice Address - State:GA
Practice Address - Zip Code:30642-5285
Practice Address - Country:US
Practice Address - Phone:706-454-1394
Practice Address - Fax:706-454-1397
Is Sole Proprietor?:No
Enumeration Date:2016-08-11
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT012498225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPT012498OtherPT LICENSE