Provider Demographics
NPI:1417725268
Name:BOATWRIGHT, GRANT (LPC-A)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:
Last Name:BOATWRIGHT
Suffix:
Gender:M
Credentials:LPC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3613 W PIONEER PKWY STE A
Mailing Address - Street 2:
Mailing Address - City:PANTEGO
Mailing Address - State:TX
Mailing Address - Zip Code:76013-4517
Mailing Address - Country:US
Mailing Address - Phone:817-646-6823
Mailing Address - Fax:
Practice Address - Street 1:3613 W PIONEER PKWY STE A
Practice Address - Street 2:
Practice Address - City:PANTEGO
Practice Address - State:TX
Practice Address - Zip Code:76013-4517
Practice Address - Country:US
Practice Address - Phone:817-646-6823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-12
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX93448101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional