Provider Demographics
NPI:1649696352
Name:GRANT, RENEE
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:
Last Name:GRANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 25247
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-5004
Mailing Address - Country:US
Mailing Address - Phone:910-460-6165
Mailing Address - Fax:
Practice Address - Street 1:2106 HOPE MILLS RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-4226
Practice Address - Country:US
Practice Address - Phone:910-460-6165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-05
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA9631101YM0800X
NC9631101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC101Y00000XMedicaid