Provider Demographics
NPI:1619014255
Name:GRANTHAM, ANISA D (LPC, NCAC)
Entity Type:Individual
Prefix:
First Name:ANISA
Middle Name:D
Last Name:GRANTHAM
Suffix:
Gender:F
Credentials:LPC, NCAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:613 TOWNE PARK DR W STE 103
Mailing Address - Street 2:PO BOX 1834
Mailing Address - City:RINCON
Mailing Address - State:GA
Mailing Address - Zip Code:31326-9098
Mailing Address - Country:US
Mailing Address - Phone:912-826-0918
Mailing Address - Fax:912-826-0959
Practice Address - Street 1:613 TOWNE PARK DR W STE 103
Practice Address - Street 2:
Practice Address - City:RINCON
Practice Address - State:GA
Practice Address - Zip Code:31326-9098
Practice Address - Country:US
Practice Address - Phone:912-826-0918
Practice Address - Fax:912-826-0959
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA101YA0400X
GA004189101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)