Basic Information
| Provider Information | |||||||||
| NPI: | 1639543150 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRANQUIST | ||||||||
| FirstName: | TAYLOR | ||||||||
| MiddleName: | ALEXIS | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1866 | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543051866 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204457222 | ||||||||
| FaxNumber: | 9204457289 | ||||||||
| Practice Location | |||||||||
| Address1: | 218 S HWY 141 | ||||||||
| Address2: | |||||||||
| City: | CRIVITZ | ||||||||
| State: | WI | ||||||||
| PostalCode: | 541141677 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7158547761 | ||||||||
| FaxNumber: | 7158547785 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2015 | ||||||||
| LastUpdateDate: | 12/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 14780-24 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 5501019200 | MI | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.