Provider Demographics
NPI:1871863647
Name:GRANGER, NATHANIEL JR
Entity Type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:
Last Name:GRANGER
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8940 MELBOURNE DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-7234
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7400 E ARAPAHOE RD
Practice Address - Street 2:SUITE 212
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80112-1279
Practice Address - Country:US
Practice Address - Phone:303-741-1077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-10
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO11274103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical