Provider Demographics
NPI:1992308514
Name:GRANT, CHRISTINA
Entity type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:
Last Name:GRANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6909 N STATE ROUTE 66 LOT 91
Mailing Address - Street 2:
Mailing Address - City:DEFIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:43512-8637
Mailing Address - Country:US
Mailing Address - Phone:419-966-9929
Mailing Address - Fax:
Practice Address - Street 1:8401 N STATE ROUTE 66
Practice Address - Street 2:
Practice Address - City:DEFIANCE
Practice Address - State:OH
Practice Address - Zip Code:43512-8252
Practice Address - Country:US
Practice Address - Phone:419-966-9929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities