=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376653204
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID GRANT MPT, COMT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2006
-----------------------------------------------------
Last Update Date | 08/08/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11330 OLIVE BLVD STE 130
-----------------------------------------------------
City | CREVE COEUR
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63141-7149
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-896-2205
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 647 SPIRIT AIRPARK WEST DR STE 101
-----------------------------------------------------
City | CHESTERFIELD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63005-1032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-223-5700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------