Healthcare Provider Details

I. General information

NPI: 1437377785
Provider Name (Legal Business Name): ROGER GRANJEAN LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 BALLARD ST
ALTAMONTE SPRINGS FL
32701-5441
US

IV. Provider business mailing address

646 S GRAND HWY
CLERMONT FL
34711-3200
US

V. Phone/Fax

Practice location:
  • Phone: 407-339-7451
  • Fax: 407-862-2737
Mailing address:
  • Phone: 646-208-2197
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberPSW665
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: