Healthcare Provider Details

I. General information

NPI: 1316906936
Provider Name (Legal Business Name): JOSEPH D GRANT PT ATC EDM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2006
Last Update Date: 10/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4740 MAIN ST
WAITSFIELD VT
05673
US

IV. Provider business mailing address

4740 MAIN ST
WAITSFIELD VT
05673
US

V. Phone/Fax

Practice location:
  • Phone: 802-496-4292
  • Fax: 802-496-4262
Mailing address:
  • Phone: 802-496-4292
  • Fax: 802-496-4262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number040.0002677
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: