Healthcare Provider Details

I. General information

NPI: 1265542641
Provider Name (Legal Business Name): TIMOTHY LEE GRANT MHPP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 08/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3111 S 70TH ST
FORT SMITH AR
72903-5017
US

IV. Provider business mailing address

PO BOX 11818
FORT SMITH AR
72917-1818
US

V. Phone/Fax

Practice location:
  • Phone: 479-452-6650
  • Fax: 479-458-5847
Mailing address:
  • Phone: 479-452-6650
  • Fax: 479-458-5847

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLADAC 0190L
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: