Provider Demographics
NPI:1053135988
Name:GRANT, RUSSELL J II (PT, DPT)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:J
Last Name:GRANT
Suffix:II
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 LAFAYETTE ST STE 105
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARA
Mailing Address - State:CA
Mailing Address - Zip Code:95050-4966
Mailing Address - Country:US
Mailing Address - Phone:408-293-7794
Mailing Address - Fax:408-638-2503
Practice Address - Street 1:900 LAFAYETTE ST STE 105
Practice Address - Street 2:
Practice Address - City:SANTA CLARA
Practice Address - State:CA
Practice Address - Zip Code:95050-4966
Practice Address - Country:US
Practice Address - Phone:408-293-7794
Practice Address - Fax:408-638-2503
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-07
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3071332251X0800X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist