Provider Demographics
NPI:1457879256
Name:GRAN, LORI LEIGH (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:MRS
First Name:LORI
Middle Name:LEIGH
Last Name:GRAN
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:LEIGH
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHYSICAL THERAPIST
Mailing Address - Street 1:177 NORTHBAY CT
Mailing Address - Street 2:
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034-2994
Mailing Address - Country:US
Mailing Address - Phone:314-565-8481
Mailing Address - Fax:
Practice Address - Street 1:11210 SCHUETZ RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63146-4933
Practice Address - Country:US
Practice Address - Phone:314-993-9888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-01
Last Update Date:2017-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR1379225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist