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General NPI Number Information
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NPI Number | 1063574994
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Entity Type | Individual
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Provider Name | BRIAN WILLIAM GRANT PH. D.
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Gender | Male
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Dates
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Enumeration Date | 12/15/2006
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Last Update Date | 08/17/2009
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Provider Practice Location Address
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Address Line | 921 E 86TH ST
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City | INDIANAPOLIS
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State | IN
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Zip | 46240-1859
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Country | US
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Telephone | 317-590-2727
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Fax | 317-669-2096
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Provider Business Mailing Address
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Address Line | 9507 CADBURY CIR
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City | INDIANAPOLIS
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State | IN
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Zip | 46260-1000
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Country | US
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Telephone | 317-590-2727
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Fax | 317-669-2096
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TH0100X
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Taxonomy Name | Health Service Psychologist
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License Number | 20090164A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 35000590A
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License Number State | IN
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