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General NPI Number Information
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NPI Number | 1639578974
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Entity Type | Individual
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Provider Name | DIANNA GRANTHAM LAC, LCPC
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Gender | Female
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Dates
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Enumeration Date | 08/21/2014
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Last Update Date | 08/29/2017
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Provider Practice Location Address
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Address Line | 2475 VILLAGE LN STE 101
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City | BILLINGS
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State | MT
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Zip | 59102-2497
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Country | US
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Telephone | 406-927-6119
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 30864
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City | BILLINGS
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State | MT
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Zip | 59107-0864
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Country | US
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Telephone |
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Fax |
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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 | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 0100919564120
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License Number State | MT
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 25244
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License Number State | MT
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