Provider Demographics
NPI:1164101853
Name:GRANT, STEPHEN BERNARD
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:BERNARD
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:PO BOX 3496
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30048-3496
Mailing Address - Country:US
Mailing Address - Phone:770-330-6987
Mailing Address - Fax:866-651-0172
Practice Address - Street 1:2195 W HIGHTOWER TRL
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-1820
Practice Address - Country:US
Practice Address - Phone:770-330-6987
Practice Address - Fax:866-651-0172
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-12
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty