Healthcare Provider Details

I. General information

NPI: 1639622152
Provider Name (Legal Business Name): DAVID DUPRIEST GRANT LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2016
Last Update Date: 04/26/2023
Certification Date: 04/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 SAGE MEADOWS CT
O FALLON MO
63366-4189
US

IV. Provider business mailing address

5 SAGE MEADOWS CT
O FALLON MO
63366-4189
US

V. Phone/Fax

Practice location:
  • Phone: 803-325-5427
  • Fax:
Mailing address:
  • Phone: 314-474-0015
  • Fax: 314-782-5387

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2022004385
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: