Provider Demographics
NPI:1023846136
Name:GRUNDY, CONNOR (LAC)
Entity type:Individual
Prefix:
First Name:CONNOR
Middle Name:
Last Name:GRUNDY
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2295 W MAGEE RD UNIT 105
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85742-4316
Mailing Address - Country:US
Mailing Address - Phone:520-257-1168
Mailing Address - Fax:
Practice Address - Street 1:2295 W MAGEE RD UNIT 105
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85742-4316
Practice Address - Country:US
Practice Address - Phone:520-257-1168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-22
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-22306101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty