Provider Demographics
NPI:1730910779
Name:CAMPBELL, GRANT AUGUSTINE (DPT)
Entity type:Individual
Prefix:
First Name:GRANT
Middle Name:AUGUSTINE
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5380 PARKS AVE NE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44641-9587
Mailing Address - Country:US
Mailing Address - Phone:330-575-6197
Mailing Address - Fax:
Practice Address - Street 1:1220 W STATE ST
Practice Address - Street 2:
Practice Address - City:ALLIANCE
Practice Address - State:OH
Practice Address - Zip Code:44601-4626
Practice Address - Country:US
Practice Address - Phone:330-823-4263
Practice Address - Fax:330-823-4260
Is Sole Proprietor?:No
Enumeration Date:2024-08-12
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH021343225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist