Healthcare Provider Details

I. General information

NPI: 1598494882
Provider Name (Legal Business Name): GRANT SANDROCK CDCA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2022
Last Update Date: 05/22/2025
Certification Date: 05/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

143 GOUGLER AVE
KENT OH
44240-2401
US

IV. Provider business mailing address

209 S CHESTNUT ST STE 302
RAVENNA OH
44266-3029
US

V. Phone/Fax

Practice location:
  • Phone: 330-677-4124
  • Fax: 330-677-4134
Mailing address:
  • Phone: 330-297-7842
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number0002282
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: