Provider Demographics
NPI:1548200322
Name:GRANTHAM, DAVID BRYANT (EDD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:BRYANT
Last Name:GRANTHAM
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:296 GAMBLE AVE
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37801-4943
Mailing Address - Country:US
Mailing Address - Phone:865-980-6464
Mailing Address - Fax:865-977-6823
Practice Address - Street 1:296 GAMBLE AVE
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37801-4943
Practice Address - Country:US
Practice Address - Phone:865-980-6464
Practice Address - Fax:865-977-6823
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLPC0000001693101YP2500X
TNLMT0000000581106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS431961623OtherTAX ID
TN015174OtherBLUE CROSS