Provider Demographics
NPI:1508413287
Name:ANDERSON, GRANT LESLEY (LMHC)
Entity Type:Individual
Prefix:MR
First Name:GRANT
Middle Name:LESLEY
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4150 ILLINOIS RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-1208
Mailing Address - Country:US
Mailing Address - Phone:260-702-3778
Mailing Address - Fax:
Practice Address - Street 1:5110 COMMERCE SQUARE DR STE F
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-9244
Practice Address - Country:US
Practice Address - Phone:317-540-3314
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-19
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC015002101YM0800X
OHE.2202961101YM0800X
IN98002878A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health