Provider Demographics
NPI:1821368432
Name:SALLY LEWIS GRANT, LLC
Entity Type:Organization
Organization Name:SALLY LEWIS GRANT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:L
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:LCAS
Authorized Official - Phone:919-920-3910
Mailing Address - Street 1:PO BOX 10174
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27532-0174
Mailing Address - Country:US
Mailing Address - Phone:919-920-3910
Mailing Address - Fax:
Practice Address - Street 1:2500 PEACHTREE ST
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534-4312
Practice Address - Country:US
Practice Address - Phone:919-920-3910
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-12
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty