Provider Demographics
NPI:1487254959
Name:GRANT, RANDOLPH R
Entity type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:R
Last Name:GRANT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 S WORTHEN ST
Mailing Address - Street 2:
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801-3081
Mailing Address - Country:US
Mailing Address - Phone:509-662-6761
Mailing Address - Fax:509-663-3182
Practice Address - Street 1:145 S WORTHEN ST
Practice Address - Street 2:
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801-3081
Practice Address - Country:US
Practice Address - Phone:509-662-6761
Practice Address - Fax:509-663-3182
Is Sole Proprietor?:No
Enumeration Date:2020-10-26
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health