Provider Demographics
NPI:1497713952
Name:BERRY, GRANT ANDERSON (MACCCA)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:ANDERSON
Last Name:BERRY
Suffix:
Gender:M
Credentials:MACCCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:870 STATE FARM RD
Mailing Address - Street 2:STE 303
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607-4861
Mailing Address - Country:US
Mailing Address - Phone:828-264-4545
Mailing Address - Fax:828-264-3279
Practice Address - Street 1:870 STATE FARM RD
Practice Address - Street 2:STE 303
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607-4861
Practice Address - Country:US
Practice Address - Phone:828-264-4545
Practice Address - Fax:828-264-3279
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2700231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7411785Medicaid
NC1497713952OtherNPI