Provider Demographics
NPI:1285187856
Name:GRANT, WILL WAYNE (CSAC)
Entity Type:Individual
Prefix:MR
First Name:WILL
Middle Name:WAYNE
Last Name:GRANT
Suffix:
Gender:M
Credentials:CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94 SWIFT CREEK RD
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:NC
Mailing Address - Zip Code:27577-9321
Mailing Address - Country:US
Mailing Address - Phone:919-422-0104
Mailing Address - Fax:919-934-2053
Practice Address - Street 1:607 BENSON RD
Practice Address - Street 2:
Practice Address - City:GARNER
Practice Address - State:NC
Practice Address - Zip Code:27529-3988
Practice Address - Country:US
Practice Address - Phone:919-422-0104
Practice Address - Fax:919-934-2053
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-29
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 101Y00000X, 101YP2500X
NC101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC22647OtherNCSAPPB