Provider Demographics
NPI:1487214334
Name:GRANBERRY, SANDRA E (MS)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:E
Last Name:GRANBERRY
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3451 RIVERINA DR
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32514-8158
Mailing Address - Country:US
Mailing Address - Phone:850-462-1611
Mailing Address - Fax:850-462-1612
Practice Address - Street 1:7100 PLANTATION RD STE 10
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-6234
Practice Address - Country:US
Practice Address - Phone:850-462-1611
Practice Address - Fax:850-462-1612
Is Sole Proprietor?:No
Enumeration Date:2019-06-13
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH16115101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health