Provider Demographics
NPI:1578112686
Name:GRANDBERRY, HENRY DEWAYNE
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:DEWAYNE
Last Name:GRANDBERRY
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:PO BOX 845
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:LA
Mailing Address - Zip Code:71366-0845
Mailing Address - Country:US
Mailing Address - Phone:318-535-4756
Mailing Address - Fax:
Practice Address - Street 1:501 HANCOCK
Practice Address - Street 2:501 HANCOCK
Practice Address - City:SAINT JOSEPH
Practice Address - State:LA
Practice Address - Zip Code:71366
Practice Address - Country:US
Practice Address - Phone:318-535-4756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-11
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LANA225XR0403X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XR0403XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistDriving and Community Mobility
Provider Identifiers
StateIdentifier IDID TypeIssuer
LANAMedicaid
LANAOtherNA