1114589272 NPI number — JANIE GRANT OT

Table of content: JANIE GRANT OT (NPI 1114589272)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114589272 NPI number — JANIE GRANT OT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRANT
Provider First Name:
JANIE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114589272
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/28/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
301 NORTH AVE UNIT 102
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN RAFAEL
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94903-5557
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-640-3359
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 TAMAL PLZ STE 525&527
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORTE MADERA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94925-1151
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
415-531-3027
Provider Business Practice Location Address Fax Number:
941-655-8839
Provider Enumeration Date:
06/28/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  19097 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 19097 . This is a "OCCUPATIONAL THERAPIST LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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