Provider Demographics
NPI:1033554852
Name:GRANT, CRYSTAL ADRAINE (MS)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:ADRAINE
Last Name:GRANT
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 20543
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27619-0543
Mailing Address - Country:US
Mailing Address - Phone:919-841-6267
Mailing Address - Fax:
Practice Address - Street 1:1512 SUNBOW FALLS LN
Practice Address - Street 2:301
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-8130
Practice Address - Country:US
Practice Address - Phone:919-841-6267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-07
Last Update Date:2013-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3128-A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3128-AOtherLCASA