=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063978898
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HEATHER GRANT LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/18/2019
-----------------------------------------------------
Last Update Date | 02/18/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 675 E 16TH ST STE 55
-----------------------------------------------------
City | HOLLAND
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49423-5807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-878-1841
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3825 121ST AVE
-----------------------------------------------------
City | ALLEGAN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49010-9445
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-878-1841
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 7501000725
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------