MEDICARE: MARSHA L. GRANT-FORD ATC, PHD

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	25MT00054200	NJ
2	2255A2300X	Athletic Trainer	RT000129A	PA

General Provider Information

NPI Number	:	1679647911
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARSHA L. GRANT-FORD ATC, PHD

Provider Business Mailing Address
First Line	:	65 PENOBSCOT ST
Second Line	:
City	:	CLIFTON
State	:	NJ
Zip	:	07013-2017
Country	:	US
Telephone Number	:	973-470-9968
Fax Number	:	973-470-9964

Provider Business Practice Location Address
First Line	:	1 NORMAL AVE
Second Line	:
City	:	UPPER MONTCLAIR
State	:	NJ
Zip	:	07043-1624
Country	:	US
Telephone Number	:	973-655-5243
Fax Number	:

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

Provider Enumeration Date	:	11/20/2006
Last Update Date	:	07/08/2007

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