1225539604 NPI number — GRAND THERAPY LLC

Table of content: (NPI 1225539604)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225539604 NPI number — GRAND THERAPY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRAND THERAPY LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1225539604
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/28/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3701 DURLEY LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GWYNN OAK
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21207-3855
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-803-8731
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3701 DURLEY LN # ME
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GWYNN OAK
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21207-3855
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-803-8731
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/22/2018

Additional Information

Authorized Official

Authorized Official Last Name:
TOWNSEND
Authorized Official First Name:
KIMBERLY
Authorized Official Middle Name:
SHARRI
Authorized Official Title or Position:
OWNER/OCCUPATIONAL THERAPIST
Authorized Official Telephone Number:
757-803-8731

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  07253 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1356849624 . This is a "PROVIDER NPI" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: $$$$$$$$$ . This is a "SOCIAL" identifier . This identifiers is of the category "OTHER".




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