Healthcare Provider Details

I. General information

NPI: 1477209542
Provider Name (Legal Business Name): CHRISTOPHER LARRY GRANT R.EEG T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2022
Last Update Date: 02/26/2022
Certification Date: 02/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1638 OWEN DR
FAYETTEVILLE NC
28304-3424
US

IV. Provider business mailing address

716 MILL BAY DR
STEDMAN NC
28391-8453
US

V. Phone/Fax

Practice location:
  • Phone: 910-615-4000
  • Fax:
Mailing address:
  • Phone: 910-916-2319
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberN
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: