Provider Demographics
NPI:1326379140
Name:GRANNUM, TRESCA SUSAN (LPC)
Entity Type:Individual
Prefix:MS
First Name:TRESCA
Middle Name:SUSAN
Last Name:GRANNUM
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 W NEW HOPE DR
Mailing Address - Street 2:SUITE 704
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-6784
Mailing Address - Country:US
Mailing Address - Phone:512-246-8870
Mailing Address - Fax:
Practice Address - Street 1:921 W NEW HOPE DR
Practice Address - Street 2:SUITE 704
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-6784
Practice Address - Country:US
Practice Address - Phone:512-246-8870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-18
Last Update Date:2010-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX63896101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional