Healthcare Provider Details

I. General information

NPI: 1144137837
Provider Name (Legal Business Name): GRANT COOLEY-SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2026
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 TEACO RD
KENNETT MO
63857-3239
US

IV. Provider business mailing address

131 ACOM ST
WARDELL MO
63879-9739
US

V. Phone/Fax

Practice location:
  • Phone: 870-565-9776
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: