Provider Demographics
NPI:1104297670
Name:GRANT, LATRISHA CATRELL (LMT)
Entity type:Individual
Prefix:
First Name:LATRISHA
Middle Name:CATRELL
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 1:6463 LIVEWOOD OAKS DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32818-2735
Mailing Address - Country:US
Mailing Address - Phone:407-209-6344
Mailing Address - Fax:
Practice Address - Street 1:6463 LIVEWOOD OAKS DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32818-2735
Practice Address - Country:US
Practice Address - Phone:407-209-6344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-09
Last Update Date:2015-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA77171174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMA77171OtherMASSAGE THERAPIST LICENSE NUMBER