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General NPI Number Information
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NPI Number | 1295284339
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Entity Type | Organization
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Legal Business Name | SHANNON GRANT LLC
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Dates
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Enumeration Date | 09/30/2016
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Last Update Date | 09/30/2016
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Provider Practice Location Address
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Address Line | 3801 ATRISCO DR NW SUITE F
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City | ALBUQUERQUE
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State | NM
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Zip | 87120-1688
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Country | US
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Telephone | 505-980-5513
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Fax |
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Provider Business Mailing Address
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Address Line | 5831 BURGOS AVE NW
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City | ALBUQUERQUE
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State | NM
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Zip | 87114-5497
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Country | US
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Telephone | 505-980-5513
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Fax |
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Authorized Official
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Title or Position | THERAPIST/OWNER
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Name | SHANNON RAE GRANT
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Credential | LPCC
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Telephone | 505-980-5513
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 0129011
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License Number State | NM
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