Provider Demographics
NPI:1124562566
Name:ROBERT JASON GRANT ED.D AUTPLAY THERAPY CLINIC
Entity Type:Organization
Organization Name:ROBERT JASON GRANT ED.D AUTPLAY THERAPY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JASON
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:EDD, LPC, RPT-S
Authorized Official - Phone:417-755-9042
Mailing Address - Street 1:1613 W ELFINDALE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-1287
Mailing Address - Country:US
Mailing Address - Phone:417-755-9042
Mailing Address - Fax:855-425-0096
Practice Address - Street 1:1613 W ELFINDALE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-1287
Practice Address - Country:US
Practice Address - Phone:417-755-9042
Practice Address - Fax:855-425-0096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-04
Last Update Date:2016-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001008080101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty