Provider Demographics
NPI:1316906936
Name:GRANT, JOSEPH D (PT ATC EDM)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:D
Last Name:GRANT
Suffix:
Gender:M
Credentials:PT ATC EDM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4740 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WAITSFIELD
Mailing Address - State:VT
Mailing Address - Zip Code:05673
Mailing Address - Country:US
Mailing Address - Phone:802-496-4292
Mailing Address - Fax:802-496-4262
Practice Address - Street 1:4740 MAIN ST
Practice Address - Street 2:
Practice Address - City:WAITSFIELD
Practice Address - State:VT
Practice Address - Zip Code:05673
Practice Address - Country:US
Practice Address - Phone:802-496-4292
Practice Address - Fax:802-496-4262
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2013-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT040.0002677225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT00019191OtherBCBS
VN1655Medicare ID - Type Unspecified