Provider Demographics
NPI:1730220179
Name:GRANT, ERICA (OTRL)
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:
Last Name:GRANT
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:REAR 416 PUTNAM ST
Mailing Address - Street 2:
Mailing Address - City:WEST HAZLETON
Mailing Address - State:PA
Mailing Address - Zip Code:18202
Mailing Address - Country:US
Mailing Address - Phone:570-453-3580
Mailing Address - Fax:
Practice Address - Street 1:221 W TAMARACK ST
Practice Address - Street 2:PINDAR PHYSICAL THERAPY INC
Practice Address - City:HAZLETON
Practice Address - State:PA
Practice Address - Zip Code:18201
Practice Address - Country:US
Practice Address - Phone:570-401-6566
Practice Address - Fax:570-501-2435
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC009136225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA089010TKRMedicare ID - Type Unspecified