Provider Demographics
NPI:1306296736
Name:GRAN, MEGAN LILL (DPT)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:LILL
Last Name:GRAN
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 1:1234 WHITEFISH STAGE
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-2753
Mailing Address - Country:US
Mailing Address - Phone:406-756-7878
Mailing Address - Fax:406-309-2579
Practice Address - Street 1:103 WHITEWATER ST STE D
Practice Address - Street 2:
Practice Address - City:POLSON
Practice Address - State:MT
Practice Address - Zip Code:59860-4502
Practice Address - Country:US
Practice Address - Phone:406-883-8101
Practice Address - Fax:406-883-8102
Is Sole Proprietor?:No
Enumeration Date:2016-06-16
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPTP-PT-TMP11073225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTPTP-PT-TEMP-11073OtherSTATE PT LICENSE