Provider Demographics
NPI:1467221036
Name:GRANGER, STEVEN KELLY
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:KELLY
Last Name:GRANGER
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 1:465 PONDEROSA DR
Mailing Address - Street 2:
Mailing Address - City:THOMASTON
Mailing Address - State:GA
Mailing Address - Zip Code:30286
Mailing Address - Country:US
Mailing Address - Phone:470-296-5608
Mailing Address - Fax:
Practice Address - Street 1:465 PONDEROSA DR
Practice Address - Street 2:
Practice Address - City:THOMASTON
Practice Address - State:GA
Practice Address - Zip Code:30286-1356
Practice Address - Country:US
Practice Address - Phone:470-296-5608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-25
Last Update Date:2023-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes102X00000XBehavioral Health & Social Service ProvidersPoetry Therapist
No101200000XBehavioral Health & Social Service ProvidersDrama TherapistGroup - Multi-Specialty
No2251C2600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistCardiopulmonary
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA705007343Medicaid