Provider Demographics
NPI:1821552944
Name:GRANT, MIRRYIAN CLARISSA
Entity Type:Individual
Prefix:
First Name:MIRRYIAN
Middle Name:CLARISSA
Last Name:GRANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:671 HENDERSON DR
Mailing Address - Street 2:
Mailing Address - City:SENECA
Mailing Address - State:SC
Mailing Address - Zip Code:29678-1701
Mailing Address - Country:US
Mailing Address - Phone:864-624-6922
Mailing Address - Fax:864-467-3757
Practice Address - Street 1:671 HENDERSON DR
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29678-1701
Practice Address - Country:US
Practice Address - Phone:864-624-6922
Practice Address - Fax:864-467-3757
Is Sole Proprietor?:No
Enumeration Date:2019-01-23
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)