Provider Demographics
NPI:1487709481
Name:GRANBERRY, ANTHONY A (THD, LPC, LMFT)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:A
Last Name:GRANBERRY
Suffix:
Gender:M
Credentials:THD, LPC, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1276 MCCONNELL DR STE A
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-3533
Mailing Address - Country:US
Mailing Address - Phone:404-954-2324
Mailing Address - Fax:
Practice Address - Street 1:1276 MCCONNELL DR STE A
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-3533
Practice Address - Country:US
Practice Address - Phone:404-954-2324
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP1600X
GAMFT001232106H00000X
GALPC005075101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA219747233AMedicaid