Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 224Z00000X | Occupational Therapy Assistant | 14435 | FL |
NPI | 1023485653 |
---|---|
Provider Name | Tisha Grant |
First Address | Bradenton, FL 34209-2215 |
Second Address | Tampa, FL 33625-4000 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 31/08/2015 |
Last Update Date | 31/08/2015 |