Healthcare Provider Details

I. General information

NPI: 1205215266
Provider Name (Legal Business Name): BRIAN P GRANT NPP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2015
Last Update Date: 08/14/2021
Certification Date: 08/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54 DALFONSO RD
NEWBURGH NY
12550-7203
US

IV. Provider business mailing address

54 DALFONSO RD
NEWBURGH NY
12550-7203
US

V. Phone/Fax

Practice location:
  • Phone: 845-541-3145
  • Fax:
Mailing address:
  • Phone: 845-541-3145
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberF403508
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: