1619014255 NPI number — ANISA D GRANTHAM LPC, NCAC

Table of content: ANISA D GRANTHAM LPC, NCAC (NPI 1619014255)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619014255 NPI number — ANISA D GRANTHAM LPC, NCAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRANTHAM
Provider First Name:
ANISA
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC, NCAC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619014255
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/14/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
613 TOWNE PARK DR W STE 103
Provider Second Line Business Mailing Address:
PO BOX 1834
Provider Business Mailing Address City Name:
RINCON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31326-9098
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-826-0918
Provider Business Mailing Address Fax Number:
912-826-0959

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
613 TOWNE PARK DR W STE 103
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RINCON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31326-9098
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-826-0918
Provider Business Practice Location Address Fax Number:
912-826-0959
Provider Enumeration Date:
01/31/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: 004189 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)