Provider Demographics
NPI:1063978898
Name:GRANT, HEATHER (LMT)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:GRANT
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3825 121ST AVE
Mailing Address - Street 2:
Mailing Address - City:ALLEGAN
Mailing Address - State:MI
Mailing Address - Zip Code:49010-9445
Mailing Address - Country:US
Mailing Address - Phone:231-878-1841
Mailing Address - Fax:
Practice Address - Street 1:675 E 16TH ST STE 55
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-5807
Practice Address - Country:US
Practice Address - Phone:231-878-1841
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-18
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501000725225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist