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General NPI Number Information
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NPI Number | 1609363100
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Entity Type | Individual
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Provider Name | COURTNEY MAE GRAMLEY LAT, ATC
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Gender | Female
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Dates
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Enumeration Date | 04/19/2018
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Last Update Date | 04/19/2018
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Provider Practice Location Address
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Address Line | 1201 WESLEYAN ST.
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City | FORT WORTH
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State | TX
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Zip | 76105
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Country | US
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Telephone | 309-826-8892
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Fax |
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Provider Business Mailing Address
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Address Line | 3617 VIENNE PL APT 2104
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City | FORT WORTH
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State | TX
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Zip | 76244-9662
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Country | US
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Telephone | 309-826-8892
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 2000024157
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License Number State |
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Taxonomy #2
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 096.004271
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License Number State | IL
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Taxonomy #3
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | AT6939
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License Number State | TX
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