Provider Demographics
NPI:1003519463
Name:GRANSTROM, IRVIN SHUHEI (MFT-I, CADC-I)
Entity type:Individual
Prefix:
First Name:IRVIN
Middle Name:SHUHEI
Last Name:GRANSTROM
Suffix:
Gender:M
Credentials:MFT-I, CADC-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3680 N RANCHO DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89130-3180
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4221 MCLEOD DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-5215
Practice Address - Country:US
Practice Address - Phone:702-474-6450
Practice Address - Fax:702-474-6463
Is Sole Proprietor?:No
Enumeration Date:2023-03-24
Last Update Date:2025-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X
NVMI4457106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner