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General NPI Number Information
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NPI Number | 1912145400
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Entity Type | Organization
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Legal Business Name | EMERALD PALACE PRACTICE PLLC
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Dates
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Enumeration Date | 01/22/2009
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Last Update Date | 01/22/2009
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Provider Practice Location Address
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Address Line | 6200 CHASE OAKS BLVD SUITE 103
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City | PLANO
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State | TX
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Zip | 75023-4652
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Country | US
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Telephone | 214-866-9529
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Fax | 469-241-0556
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Provider Business Mailing Address
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Address Line | PO BOX 863
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City | ALLEN
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State | TX
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Zip | 75013-0014
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Country | US
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Telephone | 214-866-9529
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Fax | 469-241-0556
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Authorized Official
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Title or Position | LICENSED PROFESSIONAL COUNSELOR
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Name | MR. BRIAN R GRANDJEAN
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Credential | MA, LPC
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Telephone | 214-866-9529
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 197756
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License Number State | TX
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