Provider Demographics
NPI:1043986888
Name:BLACK, GRANT MICHAEL (PT, DPT)
Entity type:Individual
Prefix:
First Name:GRANT
Middle Name:MICHAEL
Last Name:BLACK
Suffix:
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 1:1610 DRY CREEK DR
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80503-6405
Mailing Address - Country:US
Mailing Address - Phone:720-494-4750
Mailing Address - Fax:720-494-4751
Practice Address - Street 1:1610 DRY CREEK DR
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80503-6405
Practice Address - Country:US
Practice Address - Phone:720-494-4750
Practice Address - Fax:720-494-4751
Is Sole Proprietor?:No
Enumeration Date:2021-08-20
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.0017868225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist