Provider Demographics
NPI:1679633788
Name:FLEMING, GRANT ROBERT (PHD)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:ROBERT
Last Name:FLEMING
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 WEST 31ST STREET
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001
Mailing Address - Country:US
Mailing Address - Phone:307-634-6883
Mailing Address - Fax:307-634-9462
Practice Address - Street 1:1001 WEST 31ST STREET
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001
Practice Address - Country:US
Practice Address - Phone:307-634-6883
Practice Address - Fax:307-634-9462
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2008-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY310103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY115891100Medicaid
WY115891102OtherEQUALITY CARE
W308070Medicare PIN
WY115891102OtherEQUALITY CARE