Provider Demographics
NPI:1093352288
Name:GRANGER, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:GRANGER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3240 S 45TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68106-4028
Mailing Address - Country:US
Mailing Address - Phone:531-466-2326
Mailing Address - Fax:531-772-0266
Practice Address - Street 1:6818 GROVER ST STE 301
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68106-3632
Practice Address - Country:US
Practice Address - Phone:531-466-2326
Practice Address - Fax:531-772-0266
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-06
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1326101YA0400X
IA20008101YA0400X
IA099193101YM0800X
NE2008101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10027158400Medicaid