Provider Demographics
NPI:1205114535
Name:GRANT, DANIEL HICKY (ED D)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:HICKY
Last Name:GRANT
Suffix:
Gender:M
Credentials:ED D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1061 HARMON AVE STE 1D03
Mailing Address - Street 2:
Mailing Address - City:FORT STEWART
Mailing Address - State:GA
Mailing Address - Zip Code:31314-5641
Mailing Address - Country:US
Mailing Address - Phone:912-435-6633
Mailing Address - Fax:
Practice Address - Street 1:1061 HARMON AVE STE 1D03
Practice Address - Street 2:
Practice Address - City:FORT STEWART
Practice Address - State:GA
Practice Address - Zip Code:31314-5641
Practice Address - Country:US
Practice Address - Phone:912-435-6633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-04
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY000859103G00000X, 103T00000X, 103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic