Healthcare Provider Details

I. General information

NPI: 1679647911
Provider Name (Legal Business Name): MARSHA L. GRANT-FORD ATC, PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 NORMAL AVE
UPPER MONTCLAIR NJ
07043-1624
US

IV. Provider business mailing address

65 PENOBSCOT ST
CLIFTON NJ
07013-2017
US

V. Phone/Fax

Practice location:
  • Phone: 973-655-5243
  • Fax:
Mailing address:
  • Phone: 973-470-9968
  • Fax: 973-470-9964

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number25MT00054200
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRT000129A
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: