Provider Demographics
NPI:1174388904
Name:GRENIER, IVY MORGAN (PTA)
Entity type:Individual
Prefix:
First Name:IVY
Middle Name:MORGAN
Last Name:GRENIER
Suffix:
Gender:F
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:PO BOX 291
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:NH
Mailing Address - Zip Code:03603-0291
Mailing Address - Country:US
Mailing Address - Phone:603-558-2638
Mailing Address - Fax:
Practice Address - Street 1:169 MAIN ST APT 3A
Practice Address - Street 2:
Practice Address - City:CHARLESTOWN
Practice Address - State:NH
Practice Address - Zip Code:03603-4925
Practice Address - Country:US
Practice Address - Phone:603-558-2638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-20
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1428225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty