Provider Demographics
NPI:1174142129
Name:GRANT, ALISA DIANE I
Entity type:Individual
Prefix:
First Name:ALISA
Middle Name:DIANE
Last Name:GRANT
Suffix:I
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALISA
Other - Middle Name:DIANE
Other - Last Name:GRANT
Other - Suffix:X
Other - Last Name Type:Former Name
Other - Credentials:PEER COACH
Mailing Address - Street 1:2333 ROSA L PARKS BLVD APT 5092333
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37228-1225
Mailing Address - Country:US
Mailing Address - Phone:615-887-8840
Mailing Address - Fax:615-887-8840
Practice Address - Street 1:230 VENTURE CIR
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37228-1604
Practice Address - Country:US
Practice Address - Phone:615-460-4100
Practice Address - Fax:615-460-4100
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-10
Last Update Date:2020-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN000-1005175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNZEB908011644OtherBLUE CROSS BLUE SHEILD