Healthcare Provider Details

I. General information

NPI: 1265566400
Provider Name (Legal Business Name): LARRY L GRANT LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 GRISHAM RD
ROYAL AR
71968-9563
US

IV. Provider business mailing address

141 GRISHAM RD
ROYAL AR
71968-9563
US

V. Phone/Fax

Practice location:
  • Phone: 501-282-2750
  • Fax:
Mailing address:
  • Phone: 501-282-2750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberP0607039
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: