MEDICARE: SHELBI GRANT CPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	T283421	MI

General Provider Information

NPI Number	:	1093597049
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHELBI GRANT CPT

Provider Business Mailing Address
First Line	:	6680 COOLIDGE HWY
Second Line	:
City	:	TROY
State	:	MI
Zip	:	48098-1932
Country	:	US
Telephone Number	:	810-288-1571
Fax Number	:

Provider Business Practice Location Address
First Line	:	3770 DIXIE HWY
Second Line	:
City	:	WATERFORD
State	:	MI
Zip	:	48329-4289
Country	:	US
Telephone Number	:	248-383-8117
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/16/2023
Last Update Date	:	10/16/2023

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