Provider Demographics
NPI:1134676570
Name:GRANT, LAURENCE RECIO
Entity Type:Individual
Prefix:MR
First Name:LAURENCE
Middle Name:RECIO
Last Name:GRANT
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 1:6603 WESTLAND DR
Mailing Address - Street 2:
Mailing Address - City:BROWNSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:46112-7415
Mailing Address - Country:US
Mailing Address - Phone:317-652-9084
Mailing Address - Fax:
Practice Address - Street 1:6603 WESTLAND DR
Practice Address - Street 2:
Practice Address - City:BROWNSBURG
Practice Address - State:IN
Practice Address - Zip Code:46112-7415
Practice Address - Country:US
Practice Address - Phone:317-652-9084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN08292015Medicaid