MEDICARE: DR. DALLAS L. GRANT PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0009272003	OTHER	IL	BCBS PROVIDER NUMBER

General Provider Information

NPI Number	:	1689783938
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DALLAS L. GRANT PHD

Provider Business Mailing Address
First Line	:	112 SUNSET RD
Second Line	:
City	:	DANVILLE
State	:	IL
Zip	:	61834-5900
Country	:	US
Telephone Number	:	217-442-1004
Fax Number	:	217-442-1004

Provider Business Practice Location Address
First Line	:	112 SUNSET RD
Second Line	:
City	:	DANVILLE
State	:	IL
Zip	:	61834-5900
Country	:	US
Telephone Number	:	217-442-1004
Fax Number	:	217-442-1004

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	07/08/2007

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Directions to “ DR. DALLAS L. GRANT PHD” Practice Location

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