Provider Demographics
NPI:1639622152
Name:GRANT, DAVID DUPRIEST (LCSW)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:DUPRIEST
Last Name:GRANT
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 SAGE MEADOWS CT
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366-4189
Mailing Address - Country:US
Mailing Address - Phone:314-474-0015
Mailing Address - Fax:314-782-5387
Practice Address - Street 1:5 SAGE MEADOWS CT
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366-4189
Practice Address - Country:US
Practice Address - Phone:803-325-5427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-02
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MO20220043851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO490112443Medicaid