Healthcare Provider Details

I. General information

NPI: 1790028892
Provider Name (Legal Business Name): REBECCA GRANT LMT, NMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2013
Last Update Date: 03/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9720 CANDELARIA RD NE STE B
ALBUQUERQUE NM
87112-1457
US

IV. Provider business mailing address

13316 MOUNTAIN RD NE #1208
ALBUQUERQUE NM
87112-6196
US

V. Phone/Fax

Practice location:
  • Phone: 505-228-0787
  • Fax:
Mailing address:
  • Phone: 505-228-0787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number3914
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: