Healthcare Provider Details

I. General information

NPI: 1922178417
Provider Name (Legal Business Name): JOSEPH BRUCE GRANT M.C., L.P.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1232 E BROADWAY RD STE 120
TEMPE AZ
85282-1510
US

IV. Provider business mailing address

98 E MACAW CT
QUEEN CREEK AZ
85243-3993
US

V. Phone/Fax

Practice location:
  • Phone: 480-784-1514
  • Fax: 480-967-3528
Mailing address:
  • Phone: 480-888-2053
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-10457
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: