Provider Demographics
NPI:1679599310
Name:GRAN, JEFFREY MILES (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:MILES
Last Name:GRAN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 SW 70TH AVE
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33023-1019
Mailing Address - Country:US
Mailing Address - Phone:954-893-7829
Mailing Address - Fax:954-893-7829
Practice Address - Street 1:4302 W BROWARD BLVD
Practice Address - Street 2:SUITE 800
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33317-3780
Practice Address - Country:US
Practice Address - Phone:954-893-7829
Practice Address - Fax:954-893-7829
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 5683103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE0430BMedicare PIN
FLE0430ZMedicare PIN