Provider Demographics
NPI:1154691079
Name:GRANT, KIMBERLY JAVON (LMT)
Entity type:Individual
Prefix:MISS
First Name:KIMBERLY
Middle Name:JAVON
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 1:511 ELLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:THOMSON
Mailing Address - State:GA
Mailing Address - Zip Code:30824-1624
Mailing Address - Country:US
Mailing Address - Phone:706-863-9705
Mailing Address - Fax:
Practice Address - Street 1:211 PLEASANT HOME RD
Practice Address - Street 2:SUITE F-1
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30907-0518
Practice Address - Country:US
Practice Address - Phone:706-863-9705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-09
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT007434225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist