Provider Demographics
NPI:1689783938
Name:GRANT, DALLAS L (PHD)
Entity Type:Individual
Prefix:DR
First Name:DALLAS
Middle Name:L
Last Name:GRANT
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 1:112 SUNSET RD
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61834-5900
Mailing Address - Country:US
Mailing Address - Phone:217-442-1004
Mailing Address - Fax:217-442-1004
Practice Address - Street 1:112 SUNSET RD
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61834-5900
Practice Address - Country:US
Practice Address - Phone:217-442-1004
Practice Address - Fax:217-442-1004
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0009272003OtherBCBS PROVIDER NUMBER