Provider Demographics
NPI:1194329896
Name:GRANTHAM, GINA (DPT)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:GRANTHAM
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 N WATER ST
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48708-5620
Mailing Address - Country:US
Mailing Address - Phone:989-450-3341
Mailing Address - Fax:
Practice Address - Street 1:6137 TITTABAWASSEE RD STE 3
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48603-9696
Practice Address - Country:US
Practice Address - Phone:895-580-9049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-24
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501019829208100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5501019829OtherSTATE OF MICHIGAN