Healthcare Provider Details

I. General information

NPI: 1689235996
Provider Name (Legal Business Name): KOLIANDRA GRAYSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2019
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 WARREN C COLEMAN BLVD N
CONCORD NC
28027-8318
US

IV. Provider business mailing address

4235 S STREAM BLVD
CHARLOTTE NC
28217-4588
US

V. Phone/Fax

Practice location:
  • Phone: 980-785-1113
  • Fax: 980-785-1114
Mailing address:
  • Phone: 980-785-1113
  • Fax: 980-785-1114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number221
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: