Healthcare Provider Details

I. General information

NPI: 1255447488
Provider Name (Legal Business Name): KATHY D. GRANGER PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2002 JOHNSON ST SUITE 100
JENNINGS LA
70546-3646
US

IV. Provider business mailing address

1327 DULLES DR
LAFAYETTE LA
70506-3873
US

V. Phone/Fax

Practice location:
  • Phone: 337-824-4547
  • Fax: 337-824-4548
Mailing address:
  • Phone: 337-824-4547
  • Fax: 337-824-4548

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA6997
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: