Provider Demographics
NPI:1982809489
Name:GRANT, ELIZABETH ANN (PT)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
Last Name:GRANT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:BETTY
Other - Middle Name:ANN
Other - Last Name:GRANT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1757 PORT ROAD
Mailing Address - Street 2:
Mailing Address - City:MACHIASPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04665
Mailing Address - Country:US
Mailing Address - Phone:207-255-0532
Mailing Address - Fax:715-242-1066
Practice Address - Street 1:1757 PORT ROAD
Practice Address - Street 2:
Practice Address - City:MACHIASPORT
Practice Address - State:ME
Practice Address - Zip Code:04665
Practice Address - Country:US
Practice Address - Phone:207-255-0532
Practice Address - Fax:715-242-1066
Is Sole Proprietor?:No
Enumeration Date:2007-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT348225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
011099OtherANTHEM BCBS