Provider Demographics
NPI:1437582723
Name:GRANT, DEWAYNE C
Entity Type:Individual
Prefix:MR
First Name:DEWAYNE
Middle Name:C
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 1:417 AKERS DR
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-8382
Mailing Address - Country:US
Mailing Address - Phone:678-215-8705
Mailing Address - Fax:770-898-4385
Practice Address - Street 1:124 S MAIN ST
Practice Address - Street 2:SUITE 2N
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-3599
Practice Address - Country:US
Practice Address - Phone:678-215-8705
Practice Address - Fax:770-898-4385
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-09
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC006829101YP2500X
GALPC 006829106H00000X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003160809AMedicaid
GA003152990AMedicaid