Healthcare Provider Details

I. General information

NPI: 1578112686
Provider Name (Legal Business Name): HENRY DEWAYNE GRANDBERRY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2019
Last Update Date: 09/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 HANCOCK 501 HANCOCK
SAINT JOSEPH LA
71366
US

IV. Provider business mailing address

PO BOX 845
SAINT JOSEPH LA
71366-0845
US

V. Phone/Fax

Practice location:
  • Phone: 318-535-4756
  • Fax:
Mailing address:
  • Phone: 318-535-4756
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XR0403X
TaxonomyDriving and Community Mobility Occupational Therapist
License NumberNA
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: