Healthcare Provider Details

I. General information

NPI: 1255517884
Provider Name (Legal Business Name): BRUCE N GRANT PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2008
Last Update Date: 04/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 THOMASTON ST
ZEBULON GA
30295-3387
US

IV. Provider business mailing address

410 MURRY PARK
PEACHTREE CITY GA
30269-2622
US

V. Phone/Fax

Practice location:
  • Phone: 404-960-1282
  • Fax:
Mailing address:
  • Phone: 770-710-2173
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY003711
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2011035787
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: