Healthcare Provider Details

I. General information

NPI: 1558878942
Provider Name (Legal Business Name): GRANT LAMSARGIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2018
Last Update Date: 01/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 S GRAND AVE W
SPRINGFIELD IL
62704-3885
US

IV. Provider business mailing address

1306 S BATES AVE
SPRINGFIELD IL
62704-3344
US

V. Phone/Fax

Practice location:
  • Phone: 217-744-3525
  • Fax:
Mailing address:
  • Phone: 217-825-7353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.019817
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: