Provider Demographics
NPI:1417463977
Name:GRANT, TARA L (LAC)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:L
Last Name:GRANT
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3241 32ND ST # 1
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11106-2644
Mailing Address - Country:US
Mailing Address - Phone:562-234-7502
Mailing Address - Fax:
Practice Address - Street 1:41 UNION SQ W STE 811
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-3265
Practice Address - Country:US
Practice Address - Phone:347-566-1324
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-20
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR184115171100000X
NY007578171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist