Provider Demographics
NPI:1922875475
Name:GRANNES, KEVIN J
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:J
Last Name:GRANNES
Suffix:
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 1:1216 DUNCAN RD
Mailing Address - Street 2:
Mailing Address - City:COPPERAS COVE
Mailing Address - State:TX
Mailing Address - Zip Code:76522-7409
Mailing Address - Country:US
Mailing Address - Phone:254-577-4880
Mailing Address - Fax:254-518-5300
Practice Address - Street 1:1216 DUNCAN RD
Practice Address - Street 2:
Practice Address - City:COPPERAS COVE
Practice Address - State:TX
Practice Address - Zip Code:76522-7409
Practice Address - Country:US
Practice Address - Phone:254-577-4880
Practice Address - Fax:254-518-5300
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-05
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX112058104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty