Provider Demographics
NPI:1679080519
Name:GRANT, KELSEY KATHLEEN (OTD)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:KATHLEEN
Last Name:GRANT
Suffix:
Gender:F
Credentials:OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1321 CEDAR LN
Mailing Address - Street 2:
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388-2227
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1321 CEDAR LN
Practice Address - Street 2:
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-2227
Practice Address - Country:US
Practice Address - Phone:931-222-4207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-31
Last Update Date:2017-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5742225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN5742OtherTN STATE BOARD