Provider Demographics
NPI:1568958858
Name:GRANTHAM, DARIAN L
Entity Type:Individual
Prefix:
First Name:DARIAN
Middle Name:L
Last Name:GRANTHAM
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 1:1223 PORTER ST
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27530-6713
Mailing Address - Country:US
Mailing Address - Phone:919-734-1848
Mailing Address - Fax:
Practice Address - Street 1:1223 PORTER ST
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27530-6713
Practice Address - Country:US
Practice Address - Phone:919-734-1848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-10
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC47-3535658Medicaid