Provider Demographics
NPI:1700158581
Name:GRANT, PEYTON LEON (MS)
Entity Type:Individual
Prefix:MR
First Name:PEYTON
Middle Name:LEON
Last Name:GRANT
Suffix:
Gender:M
Credentials:MS
Other - Prefix:MR
Other - First Name:PEYTON
Other - Middle Name:LEON
Other - Last Name:GRANT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS
Mailing Address - Street 1:1115 W CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-7501
Mailing Address - Country:US
Mailing Address - Phone:601-382-0859
Mailing Address - Fax:
Practice Address - Street 1:1115 W CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-7501
Practice Address - Country:US
Practice Address - Phone:601-382-0859
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-08
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA450363101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool