Healthcare Provider Details

I. General information

NPI: 1962326561
Provider Name (Legal Business Name): ALISON MARIE GRANGER MAT, ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ALLY MARIE GRANGER MAT, ATC, LAT

II. Dates (important events)

Enumeration Date: 08/06/2026
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 E 17TH ST
BLOOMINGTON IN
47408-1590
US

IV. Provider business mailing address

1001 E 17TH ST
BLOOMINGTON IN
47408-1590
US

V. Phone/Fax

Practice location:
  • Phone: 812-855-2794
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36004167A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: