Provider Demographics
NPI:1255517884
Name:GRANT, BRUCE N (PSYD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:N
Last Name:GRANT
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 MURRY PARK
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-2622
Mailing Address - Country:US
Mailing Address - Phone:770-710-2173
Mailing Address - Fax:
Practice Address - Street 1:420 THOMASTON ST
Practice Address - Street 2:
Practice Address - City:ZEBULON
Practice Address - State:GA
Practice Address - Zip Code:30295-3387
Practice Address - Country:US
Practice Address - Phone:404-960-1282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-14
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
GAPSY003711103T00000X
MO2011035787103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)