Provider Demographics
NPI:1487953352
Name:GRANT, KIMBERLY ELIZABETH (PTA)
Entity type:Individual
Prefix:MISS
First Name:KIMBERLY
Middle Name:ELIZABETH
Last Name:GRANT
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 1:6134 BRIDLEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28215-1612
Mailing Address - Country:US
Mailing Address - Phone:704-535-3446
Mailing Address - Fax:
Practice Address - Street 1:6134 BRIDLEWOOD LN
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28215-1612
Practice Address - Country:US
Practice Address - Phone:704-535-3446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-17
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA3803225200000X
SC2144225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant